L MYAT1, S MAY1
1Tamworth Hospital, Sydney, Australia
Background: Diarrhea is a frequent complication in kidney transplant recipients, resulting in a significant increase in morbidity and a poorer graft outcome. Nitazoxanide (NTZ) is a thiazolide antimicrobial developed in the 1980s. NTZ is a broad-spectrum anti-infective drug against a range of extracellular and intracellular protozoa, helminths and bacteria, in addition to viruses. Nitazoxanide acts by inhibiting pyruvate-ferredoxin oxidoreductase (PFOR) enzyme-dependent reactions necessary for anaerobic energy metabolism. Food improves oral bioavailability and no drug interactions have been found.
Case Report: 32-year-old female with end-stage renal disease secondary to IgA nephritis presented with severe diarrhoea 11 months after a non-complicated living related kidney transplant. She was on standard immunosuppression with prednisone, mycophenolate and tacrolimus. Her creatinine had increased from a base line of 126 µmol/l, eGFR 49 to 204umol/l, eGFR 27 with high tacrolimus level of 29µ gm/l. Stool multiplex PCR assays were positive for Sapovirus which from the literature is difficult to treat without reduction or cessation of mycophenolate. It is associated with prolonged viral shedding often more than 300 days. The intestinal epithelial cells may be destroyed abrogating P-glycoproteins which actively secrete the drug into intestinal lumen, thereby increasing the levels of tacrolimus. She was given a course of NTZ over 3 days with rapid resolution of her diarrhoea and a return to baseline creatinine without reduction of her immunosuppression. Her stool culture had rapid resolution of Sapovirus PCR.
Conclusion: This case adds to a very limited literature using of NTZ in transplantation and is possibly the first case of Sapovirus successfully treated with NTZ without reduction of immunosuppression. We propose that nitazoxanide could potentially be used in other viral, bacterial and protozoa diarrhea in transplant.
Nephrology Advanced Trainee