Diagnosis and management of de novo inflammatory bowel disease after solid organ transplantation in the era of biologic therapy: a case series

Abstract

Introduction: The clinical characteristics of de novo inflammatory bowel disease (dnIBD) diagnosed after solid organ transplant (SOT) are not well-described, particularly since the advent of biologic therapy for treatment of IBD.

Methods: We conducted a single-center, retrospective review of SOT recipients between 2010 and 2022 at the University of Minnesota Medical Center who were diagnosed with IBD after transplant.

Results: Of 89 patients at our center with IBD and a history of SOT, five (5.6%) patients were diagnosed with IBD post-transplant (three liver, one kidney, and one simultaneous liver and kidney): three patients were female and four were Caucasian. Mean age at transplant and IBD diagnosis were 46.7 and 49.4 years respectively. Indication for transplant were alcohol-related cirrhosis (n = 2), idiopathic fulminant hepatic failure (n = 1), metabolic dysfunction-associated steatotic liver disease (n = 1), and IgA nephropathy (n = 1). Four patients were diagnosed with ulcerative colitis (UC) and one with Crohn's disease (CD). Three patients (all with UC) required escalation to a biologic therapy. Four patients were in clinical remission from IBD at last follow-up, one patient required IBD surgery, while there was no rejection and no deaths following IBD diagnosis.

Conclusion: dnIBD post-SOT is uncommon, while newer IBD therapies may be safe and effective. Further study is required to better understand the natural history and IBD outcomes of this population relative to non-SOT patients.

Keywords: Crohn's disease; immunosuppression; inflammatory bowel disease; solid organ transplant; ulcerative colitis.

Figure 1

Endoscopic images of patients from our cohort with ulcerative colitis. (A) patient 1, rectum with diffuse erythema and congestion, ulcerated mucosa, at time of diagnosis of ulcerative proctocolitis; (B) patient 2, cecum with congestion, erosions and friability, at time of diagnosis of ulcerative pan-colitis; (C) patient 3, cecum with minimal patchy erythema and granularity, on oral mesalamine for 18 months after diagnosis of ulcerative pancolitis; (D) patient 4, sigmoid colon with diffuse edema, patchy erythema and ulcerations, at time of diagnosis of ulcerative pan-colitis.

Figure 2

Pathology images of patients from our cohort with ulcerative colitis. H&E staining showing marked lamina propria lymphoplasmacytic inflammation, irregular crypt, and neutrophilic cryptitis and crypt abscess. (A) 50X. (B) 100X. (C) 200X. (D) 200X.