title: Cryptosporidium infection after renal transplantation in an endemic area.
abstract: BACKGROUND
  Cryptosporidium is one of the common causes of infective diarrhea in post-transplant patients in endemic areas. However, data are limited on Cryptosporidium infection in recipients of solid organ transplantation. The aim of this study was to determine the incidence, disease manifestation, management, and outcome of Cryptosporidium infection in living-donor renal transplant recipients (RTR).
  
  
  METHODS
  We performed a detailed retrospective review of the data on all RTR who had diarrheal illness requiring evaluation and hospitalization, and Cryptosporidium infection.
  
  
  RESULTS
  During the study period, 119/1235 (8.98%) RTR developed diarrhea, and Cryptosporidium was found in 34/119 (28.5%). Nine of 680 (1.3%) patients were on a cyclosporine (CSA)-based regimen, and 25/643 (3.8%) patients were on a tacrolimus (Tac)-based regimen. The relative risk of developing Cryptosporidium infection was lower on the CSA-based regimen, compared with the Tac-based regimen (odds ratio [OR]: 0.35, 95% confidence interval [CI]: 0.17-0.72, P = 0.003). Twelve of the 34 patients had acute graft dysfunction, mainly caused by combined Tac toxicity and dehydration. Mean serum creatinine and trough Tac level were 2.04 ± 0.65 mg/dL and 8.24 ± 1.19 ng/dL, respectively. Nitazoxanide alone was used in 13 patients, and nitazoxanide in combination with fluoroquinolone in 21 patients, with duration of treatment ranging from 16 to 60 days. Tac was changed to CSA in 8/11 patients. The clearance of cysts and response to nitazoxanide alone were significantly lower, compared with combination therapy (61.53% vs. 95.23%, P = 0.01, 38.46 vs. 85.71%, P = 0.004, respectively). The OR for cyst clearance and response was also significantly lower with nitazoxanide alone, in comparison with combination therapy (OR: 0.65, 95% CI: 0.34-0.92, P = 0.01, OR: 0.45, 95% CI: 0.21-0.81, respectively). Four (16%) of 24 patients with response had relapse.
  
  
  CONCLUSIONS
  Patients with Tac and mycophenolate mofetil combination therapy had a significantly high risk of Cryptosporidium infection. Cryptosporidial infection may require prolonged nitazoxanide therapy, either alone or in combination, with or without reduction in immunosuppression.
authors.affiliation: Nephrology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
authors.forename: D
authors.initials: D
authors.lastname: Bhadauria
authors.forename: A
authors.initials: A
authors.lastname: Goel
authors.forename: A
authors.initials: A
authors.lastname: Kaul
authors.forename: R K
authors.initials: RK
authors.lastname: Sharma
authors.forename: A
authors.initials: A
authors.lastname: Gupta
authors.forename: V
authors.initials: V
authors.lastname: Ruhela
authors.forename: A
authors.initials: A
authors.lastname: Gupta
authors.forename: H
authors.initials: H
authors.lastname: Vardhan
authors.forename: N
authors.initials: N
authors.lastname: Prasad
mesh_terms: D000293:Adolescent; D000328:Adult; D003457:Cryptosporidiosis / Q000188:drug therapy* / Q000453:epidemiology; D003458:Cryptosporidium / Q000187:drug effects; D016572:Cyclosporine / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D007165:Immunosuppression Therapy; D007166:Immunosuppressive Agents / Q000627:therapeutic use*; D015994:Incidence; D007194:India / Q000453:epidemiology; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009173:Mycophenolic Acid / Q000627:therapeutic use*; D012189:Retrospective Studies; D016559:Tacrolimus / Q000627:therapeutic use*; D055815:Young Adult
chemical_list: D007166:Immunosuppressive Agents; D016572:Cyclosporine; D009173:Mycophenolic Acid; D016559:Tacrolimus
keywords: Cryptosporidium; diarrhea; immunosuppression; renal transplant