Gastrointestinal Complications in Patients with Chronic Kidney Disease—A 5-Year Retrospective Study from a Tertiary Referral Center

Figures & data

Table 1.  Biopsy findings and diagnosis of groups 1 and 2.

		Number of patients
Biopsy findings	Diagnosis	Group 1	Group 2
Acute inflammation of esophageal mucosa with ulceration.	Ulcerative esophagitis	7	2
Acute inflammation of esophageal mucosa with candida on the surface epithelium.	Candidal esophagitis	8	6
Acute inflammation and ulceration of esophageal mucosa with surface epithelial cells showing multinucleation and herpes virus intranuclear inclusions.	Herpes simplex esophagitis (Figure 1)	0	1
Gastric mucosal edema, hyperemia, mild inflammation, and superficial erosions with or without secondary foveolar hyperplasia and smooth muscle proliferation.	Erosive gastritis	13	1
Significant gastric mucosal acute inflammation associated with edema and hyperemia without erosions.	Acute gastritis	2	0
Same as above with more severe inflammation and hemorrhage into lamina propria.	Acute hemorrhagic gastritis	1	1
Moderate to severe acute and chronic gastric mucosal inflammation accompanied by the presence of neutrophils within the surface/glandular epithelial layer- no H. pylori	Active-chronic gastritis	5	4
Same as above with additional H. pylori demonstrated on Giemsa stain.	H. pylori associated active chronic gastritis	2	0
Inflammation of duodenal mucosa with or without ulceration	Duodenitis	7	2
Mild inflammation of duodenal mucosa with several larvae of strongyloides within glands	Strongyloides infestation (Figure 2)	0	1
Mild inflammation of colonic mucosa with no specific features	Mild-colitis, nonspecific	3	2
Mild to moderate acute inflammation of colonic mucosa, mostly confined to superficial lamina propria with or without crypt abscesses.	Infective colitis	0	5
Ulceration and necrosis of colonic mucosa with surrounding viable mucosa showing edema and hemorrhage.	Ischemic colitis (Figure 3)	5	0
Colonic mucosa with focal explosive ulceration with surrounding edema.	Pseudomembranous colitis	1	0
Mild patchy inflammation and edema of colonic mucosa with CMV inclusions in the mucosal capillary endothelium.	CMV colitis (Figure 4)	0	2
Significant crypt distortion with branching, shortening and crypt loss associated with mild to moderate colonic mucosal inflammation.	MMF-related colitis (Figures 5 and 6)	0	5

Figure 1.  Photomicrograph showing exfoliated esophageal squamous epithelial cells with herpes simplex nuclear inclusions (arrow), hematoxylin eosin stain, 400×.

Figure 2.  Duodenal mucosal biopsy showing strongyloides larvae within glands (arrow), hematoxylin eosin stain, 200×.

Figure 3.  Photomicrograph showing infarcted colonic mucosa in ischemic colitis with adjacent mucosal hemorrhage, hematoxylin eosin stain, 200×.

Figure 4.  Colonic mucosal biopsy showing CMV inclusions in mucosal capillary endothelium (arrow), hematoxylin eosin stain, 400×.

Figure 5.  Colonic mucosal biopsy showing marked crypt architectural distortion, branching and clustering of crypts, intervening widely spaced lamina propria shows edema and inflammation, features reminiscent of idiopathic inflammatory bowel disease, hematoxylin eosin stain, 200×.

Figure 6.  Colonic mucosal biopsy showing significant reduction in crypts, consistent with MMF-related toxic changes, hematoxylin eosin stain, 200×.

Table 2.  MMF-related colitis.

	Age and Sex		Time interval between commencement of immunosuppressants and presentation	Presenting symptoms	Endoscopic findings	Biopsy findings	Outcome
Case 1	28	M	6 years 7 months	Acute diarrhoea	Moderate colitis up to hepatic flexure	Oedema, mild active inflammation, focal crypt branching and decreased crypt density	Transient response to symptomatic treatment but recurrence of symptoms necessitating readjustment of MMF and subsequent graft dysfunction
Case 2	33	F	1 year 7 months	Diarrhoea of 3 weeks duration	Moderate colitis throughout the colon	Severe crypt architectural irregularities with branching, shortening, crypt loss, and moderate active inflammation with crypt abscesses	Responded to reduction in MMF but subsequently developed leucopenia necessitating drug withdrawal, currently on maintenance HD
Case 3	30	M	2 years	Chronic diarrhoea persisting over a month	Multiple aphthae throughout the colon	Severe crypt loss, focal crypt branching, moderate active inflammation with cryptitis, crypt abscesses, and reactive epithelial atypia	Symptomatic response to antibiotics and adjustment of MMF dosage. Remains stable with no colonic symptoms (1.5 years follow up)
Case 4	16	F	7 months	Fever and diarrhoea of 2 weeks duration	Patchy colitis throughout the colon	Edema, moderate crypt irregularities with branching and crypt loss, and mild active inflammation	Symptomatic response to antibiotics. Remains stable with no colonic symptoms (2 years follow-up)
Case 5	16	F	2 years	Fever, diarrhoea, and vomiting (duration not mentioned)	Moderate right sided colitis	Moderate crypt irregularities, focal crypt loss, and moderate active inflammation with crypt abscesses	No follow up available