Intestinal parasitic infections in renal transplant recipients

Abstract

Context: The magnitude of intestinal parasitic infection in renal transplant recipients requires careful consideration in the developing world. However, there have been very few studies addressing this issue in Iran. Aim: This study was conducted to determine the prevalence of intestinal parasitic infections in renal transplant recipients in Iran. Materials and Methods: Stool specimens from renal transplant recipients and control groups were obtained between June 2006 and January 2007. The samples were screened for intestinal parasitic infections using direct smear, formalin-ether sedimentation, Sheather’s flotation and modified Ziehl-Neelsen staining methods. Statistical Analysis Used: A comparison of the frequency of parasites between cases and controls was performed using Chi-square test. Subsequently, the Wilcoxon rank-sum test was used to compare multiple parasitic infections in cases and controls. P value <0.05 was considered significant. Results: Out of 150 renal transplant recipients, 33.3% (50), and out of 225 of the control group, 20% (45) were infected with one or more types of intestinal parasites. The parasites detected among patients included Entamoeba coli (10.6%), Endolimax nana (8.7%), Giardia lamblia (7.4%), Blastocystis spp. (4.7%), Iodamoeba butschlii (0.7%), Chilomastix mesnili (0.7%) and Ascaris lumbricoides (0.7%). Multiple infections were more common among renal transplant recipients group (P < 0.05). Conclusions: This study highlights the importance of testing for intestinal parasites among Iranian renal transplant recipients. Routine examinations of stool samples for parasites would significantly benefit the renal transplant recipients by contributing to reduce severity of infection. The results of this study emphasize the monitoring and stool examination for prevention of parasitic infections in renal transplant recipients.

Keywords: Intestinal parasites, prevalence, renal transplant recipients

How to cite this article:
Azami M, Sharifi M, Hejazi SH, Tazhibi M. Intestinal parasitic infections in renal transplant recipients. Ann Trop Med Public Health 2011;4:29-32
How to cite this URL:
Azami M, Sharifi M, Hejazi SH, Tazhibi M. Intestinal parasitic infections in renal transplant recipients. Ann Trop Med Public Health [serial online] 2011 [cited 2020 Aug 14];4:29-32. Available from: https://www.atmph.org/text.asp?2011/4/1/29/80533
Introduction

About 340 parasitic species infect more than 3 billion people worldwide, with varying morbidity and mortality. [1] Infections cause significant morbidity and mortality among immunosuppressed hosts. Acquisition of infection, clinical severity, and outcome of a parasitic disease depend on innate and acquired host immunity as well as on the parasite’s own response against the host when the infection is established. The incidence and prevalence of parasitic infections in transplant recipients is unknown; only a few patients are symptomatic. [2] Only 5% of known human pathogenic parasitic infections have been reported in transplant recipients. This certainly does not represent the true prevalence because only those infections that cause significant morbidity would be expected to find their way into the literature. [1] Since the use of cyclosporine has become a cornerstone in prophylactic immunosuppression, this syndrome has become exceedingly rare owing to the strong parasiticidal effect of the drug against a wide range of organisms, as documented in mice and humans. [1],[3] The new immunosuppressive drugs used to prevent graft rejection have led to an increase in parasitic infections in renal transplant recipients. The purpose of our study was to evaluate the prevalence of intestinal parasites in renal transplant recipients and compare them with healthy individuals.

Materials and Methods

This cross-sectional study was conducted in June 2006 and January 2007 at Nor Hospital, a referral hospital for kidney transplantation in Isfahan, Iran. Stool specimens were collected from 150 renal transplant recipients and 225 non-immunosuppressed cases that were from different wards and selected randomly as the control group. These samples were examined microscopically using direct and formalin-ether concentration methods. [4] In brief, samples were collected in labeled, leak-proof, and clean plastic stool cups and brought to the laboratory immediately. Direct microscopy of the smears in saline (0.85% NaCl solution) and Lugol’s iodine was performed for the detection of ova, larvae, trophozoites, and cysts of intestinal parasites. In addition, a concentration procedure was employed that involved mixing the stool samples with formalin, treating with ether, and centrifuging. The layers of ether, formalin, and debris were discarded, and the residues were used to investigate for the presence of intestinal parasites. [4] Also, we used Sheather’s flotation method and modified Ziehl-Neelson staining technique for detection of coccidian parasites.

The data were entered and analyzed using SPSS version 13 statistical package. A comparison of the frequency of parasites between cases and controls was performed using Chi-square test. Subsequently, the Wilcoxon rank-sum test was used to compare multiple parasitic infections in cases and controls. P value <0.05 was considered significant.

Results

A total of 375 fecal samples were collected for this study. One hundred and fifty patients were renal transplant recipients with a mean age of 42 years. Of these, 104 (69.4%) were males and 46 (30.6%) were females [Table 1]. The control group included 225 subjects [Table 1]. There were no statistically significant differences between males and females in both the groups (P > 0.05).

Table 1: Age and sex distribution of renal transplant recipients and controls

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Intestinal parasites were detected in 33.3% of the renal transplant recipients and in 20% of the controls. [Table 2] shows the prevalence of intestinal parasites detected in the study subject. No statistically significant difference in prevalence of individual parasite species was detected between cases and controls (P > 0.05). Protozoan intestinal parasites were common than helminthes, both in renal transplant recipients (29.4% versus 0.7%) and in controls (19.2% versus 0.9%) [Table 2] (P < 0.05).

Table 2: Prevalence of intestinal parasites in renal transplant recipients and controls

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[Table 3] shows the magnitude of single and multiple parasitic infections in renal transplant recipients and in controls. Multiple parasitic infections were observed in a total of 15 renal transplant recipients and 20 controls (P < 0.05). The species of parasites most frequently seen in multiple infections in renal transplant recipients were Entamoeba coli and Blastocystis spp.

Table 3: Single and multiple parasitic infections in renal transplant recipients and control

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Discussion

Protozoa and helminthes are among the most important pathogens that can cause infections in immunocompromised hosts. These microorganisms particularly infect individuals with impaired cellular immunity; such as those with hematological neoplasias, renal or heart transplant patients, patients using high doses of corticosteroids, and patients with acquired immunodeficiency syndrome. [5]

In this study, we evaluated the prevalence of intestinal parasites in renal transplant recipients and compared them with healthy individuals. According to the results, the overall prevalence of either helminthes or protozoan parasites was not statistically different between the two groups. This observation agrees with several reports stating that intestinal parasitic infections in immunocompromised patients depend largely on the prevalence of intestinal parasitism in the local community. [6],[7]

Prevalence of intestinal parasites in renal transplant recipients is not known in Iran, so we had to compare our results with that of other studies done on immunocompromised individuals such as HIV patients. Intestinal parasitic infection did not appear to be highly prevalent in our population; an intermediate to low level of prevalence, in comparison with data from prevalence studies carried out in other regions, was found. [8],[9] In a recent study that was carried out on renal transplant recipients, the overall prevalence of intestinal parasites was 2.4%. [10]

In the present study, Ent. coli was the first most prevalent parasite detected in both the groups which showed no significant difference and was followed by Endolimax nana and Giardia lamblia. In a recent study in Iran, rate of infection with Ent. coliEnd. nana and G. lamblia in HIV patients has been reported to be 0.16, 0 and 4.1%, respectively. [6] In a study carried out on renal transplant recipients in Brazil, G. lamblia was the third most prevalent parasite (3/16) and Strongyloides stracoralis was the common parasite (11/16) in these patients. [10]

Cryptosporidium infection is prevalent in communities with overcrowding and low level of sanitation, [11] and its prevalence reaches up to 36% in certain developing countries. [12] In Iran, the exact coccidian infection rates are not known, as there are few reports on cryptosporidiosis. The previous reports indicate the prevalence of this infection in diarrhea patients to be 4.7% [13] and in HIV patients as 1.5%. [6] Its isolation rate was low in our subjects (0.4%), and was detected in the control group. This could be attributed to the relatively conserved immune status of our study subjects.

Cyclospora cayetanensis is an opportunistic protozoan related to outbreaks and to endemic areas, causing prolonged diarrhea in immunocompetent as well as in immunocompromised individuals. [14] In accordance with our study, none of the investigated specimens was positive for C. cayetanensis infection. It appears to be to rarely distributed in Iran, as there are only two cases reported so far.[15],[16]

S. stracoralis has the unique feature of transmitting from the parasitic form to the infective stage within the body, rather than emerging and forming free-living stages and causing autoinfection. [17] This may lead to latent infection for an indefinite period in an immunocompetent host, but may also cause fatal hyper-disseminated infection in organ transplant recipients, cancer and other immunosuppressive conditions. [18] In the present study, no S. stracoralis was detected in both the groups. It is a fact that the use of cyclosporine A (CsA) has become a cornerstone in prophylactic immunosuppression among renal transplant recipients. CsA, with its powerful properties of immunosuppression, acts on parasitic infections in various ways. [19] There are few articles reporting that CsA has reduced the incidence of strongyloidiasis in renal transplant recipients. [1],[20] The rate of infection with S. stracoralis in HIV patients in Iran [20] and renal transplant recipients in Brazil [10] has been reported to be 0.2 and 68.8%, respectively.

The detection of such common intestinal parasites in both patients and controls could be a reflection of the poor environmental sanitation and personal hygienic practices, which emphasize the need for intervention measures at the community level to reduce the risk factors of acquiring intestinal parasites. It was also evident that multiple parasitic infections were more common in renal transplant recipients than in controls, which strongly indicates the facilitated establishment of parasites in immunocompromised patients. It is very important to target these common infections while treating renal transplant recipients for opportunistic infections in developing countries like Iran.

In conclusion, the magnitude of intestinal parasitic infection was high both in renal transplant recipients and in controls. Routine examination of stool samples for parasites could significantly benefit the renal transplant recipients and uninfected individuals by contributing to reduce clinical severity and improving the quality of life.

References
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Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.80533

Tables

[Table 1], [Table 2], [Table 3]

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