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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 16  |  Issue : 1  |  Page : 135-137

Rectal carcinoma 27 years' postkidney transplant in a chronic hepatitis B patient - A case report


1 Department of Nephrology, Madras Medical Mission, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India
2 Department of Internal Medicine, Sri Ramachandra Institute of Higher Education and Research, Chennai, Tamil Nadu, India

Date of Submission07-Oct-2020
Date of Acceptance19-Jan-2021
Date of Web Publication31-Mar-2022

Correspondence Address:
Dr. Georgi Abraham
Department of Nephrology, Madras Medical Mission, 4th A St, Dr J. Jayalalithaa Nagar, Mogappair, Chennai - 600 037, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_128_20

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  Abstract 


Here, we report a 72-year-old male with HBsAg-positive status who had a live sibling kidney transplant 27 years ago. He was on minimal maintenance immunosuppressive therapy with prednisolone and microemulsion cyclosporine. He presented with vague abdominal symptoms and was diagnosed to have moderately differentiated adenocarcinoma of the rectum, which was treated by low anterior resection with loop ileostomy and is currently undergoing radiotherapy.

Keywords: Hepatitis B virus infection, kidney transplantation, rectal adenocarcinoma


How to cite this article:
Anupama SH, Parthasarathy R, Mathew M, Anupama PH, Abraham G. Rectal carcinoma 27 years' postkidney transplant in a chronic hepatitis B patient - A case report. Indian J Transplant 2022;16:135-7

How to cite this URL:
Anupama SH, Parthasarathy R, Mathew M, Anupama PH, Abraham G. Rectal carcinoma 27 years' postkidney transplant in a chronic hepatitis B patient - A case report. Indian J Transplant [serial online] 2022 [cited 2022 May 25];16:135-7. Available from: https://www.ijtonline.in/text.asp?2022/16/1/135/342426




  Introduction Top


Among the developing nations of South Asia, the prevalence of chronic kidney disease with hepatitis B virus (HBV) co-infection is on the rise.[1] HBV carrier state prevalence is seen in 4% of the population in India.[2] While blood transfusion, sexual contact, and injection needle-related hazards remain the predominant cause of transmission of hepatitis B infection, organ transplantation is a lesser-acknowledged cause in the transmission of HBV.[3] HBsAg-positive recipients of kidney transplantation have had a lower survival rate as opposed to negative recipients before the introduction of antiviral therapy with associated mortality attributed to progressive liver disease.[4],[5] Among the extrahepatic malignancies associated with HBV infection, colorectal carcinomas form a significant percentage.[6] A follow-up study on a sample size of 45,299 patients with chronic HBV infection showed that patients on nucleoside therapy had a higher risk of developing colorectal cancers.[7] Nucleotide analog antiviral therapy is not only associated with improved graft survival with rates comparable to HBsAg-negative recipients, but it is found to be efficient in suppressing HBV DNA as well.[8]

We present a 72-year-old male chronic HBV carrier renal transplant recipient of 27 years, who was incidentally diagnosed with rectal adenocarcinoma rarely seen post kidney transplantation. The patient underwent surgical resection and regional radiotherapy.


  Case Report Top


A 72-year-old male who received a kidney transplant from his younger brother in February 1992 on immunosuppression consisting of prednisolone, azathioprine, and cyclosporine A was found to be HBsAg positive a couple of months after transplantation while having normal graft function. Simultaneously, his donor brother tested positive for HBsAg. The patient was negative for HIV. He received hemodialysis for 5 months before transplant and was not vaccinated against HBV. Before the transplant, the patient gave a history of one episode of severe bleeding following a tooth extraction needing transfusion of three units of packed blood cells.

Graft function and survival were not compromised throughout the posttransplant period. His hepatitis B DNA viral load was found to be 22,409,975,000 IU/ml, 14,939,983,333 IU/ml, 170,000,000 IU/ml, and >10,000,000 IU/ml from 2013 to 2019. Given the high viral load, the patient was started on lamivudine 100 mg once daily, which he took for 6 months in 2013 with no efficacy. The patient was continued on prednisolone 5 mg once daily and cyclosporine 25 mg twice daily as his immunosuppressive regimen. Fibro scan of the liver done 3 years ago was not suggestive of liver disease. The patient underwent yearly assessment of serum alpha-fetoprotein and an ultrasound scan of the abdomen to rule out liver disease.

He presented on November 5, 2019, with complaints of diffuse abdominal pain and weight loss of 6 kg over 2 months. Physical examination revealed bilateral pitting pedal oedema and stable vital signs. Stool occult blood was positive. Serum carcinoembryonic antigen was 133 ng/ml (<3 ng/ml). Colonoscopy revealed a rectosigmoid growth suspicious of malignancy along with mucosal break proximal to the growth and biopsy was taken. Abdominal CT scan without contrast showed malignant growth in the rectosigmoid colon, causing a partial luminal obstruction [Figure 1]. Diagnostic laparotomy and loop sigmoid colostomy was done. Biopsy showed moderately differentiated adenocarcinoma with malignant glands and surface ulceration (×40) [Figure 2] and fused glands in cribriform pattern with brisk mitotic activity (×200) [Figure 3].
Figure 1: Abdominal computed tomography (plain) showing malignant growth in the rectosigmoid colon with partial luminal obstruction

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Figure 2: Biopsy showing moderately differentiated adenocarcinoma with malignant glands and surface ulceration (×40)

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Figure 3: Biopsy showing fused glands in cribriform pattern with brisk mitotic activity (×200)

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On November 11, 2019, the patient underwent low anterior resection of the rectal mass with a loop ileostomy. Surgical findings reported a circumferential growth in the middle one-third of the rectum extending from 7 to 12 cm from the anal verge. Margins were clear and free of tumor cells. Closure of colostomy has been planned to be done after 12 weeks. PET scan done after surgical resection of the rectal mass revealed no increased FDG tracer activity. Postoperative period was uneventful. He is undergoing local radiotherapy.

Postoperative serum creatinine is 0.58 mg/dl, and blood urea is 18 mg/dl. Ten days post resection, HBV DNA quantitative by real-time-PCR revealed viral load to be above 170,000,000 IU/ml following which the patient was initiated on treatment with entecavir 0.5 mg. Three weeks later, the HBV DNA viral load declined to 40250 IU/ml.


  Discussion Top


Malignancy accounts for one of the five major causes of death in kidney transplant recipients.[9] Hemodialysis-related hepatitis B infection associated with kidney transplantation is a significant cause of morbidity since HBsAg positivity in recipients was linked to a 2.49-fold increased risk of death post transplant.[10] This has warranted adoption of appropriate strategies to prevent HBV flare in posttransplant recipients.[11] Earlier studies have reported detrimental effects of HBV on patient and graft survival,[12],[13],[14],[15],[16] although adoption of newer antiviral agents for HBV coupled with prudent use of immunosuppressive therapy in recipients with HBsAg positivity has had a positive impact on the outcome.[3],[12] Studies are in progress to see the efficacy of lamivudine in the treatment of a mutant metastatic colorectal cancer.[17] While lamivudine, an older nucleoside analog (NA) is used in the treatment of hepatitis B, newer NA entecavir, which the patient is on now, has been noted to have >95% sustained viral remission.[18]

Our patient is a 72-year-old live renal transplant recipient and has chronic HBV infection who received his kidney from his younger brother. Routine testing for ensuring optimum liver and allograft function has been done yearly over the past 27 years. Alongside his uncompromised graft function and survival, there has been no evidence for the development of hepatocellular carcinoma commonly associated with chronic HBV carrier states. The assessment for viral load post resection of the tumor ideated the initiation of entecavir. The recent development of rectal cancer has been uncharacteristic. The median overall survival rate for immunosuppressed patients post solid organ transplant was 30.8 months.[19] To our knowledge, this unique patient who had hepatitis B infection with a well-functioning kidney allograft is the first case report of rectal carcinoma due to prolonged viral infection.


  Conclusion Top


Our patient with HBV infection dating from 1992 on minimal immunosuppressive therapy with adequate graft function was found to have incidental rectal carcinoma with no metastasis. He is undergoing radiotherapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Puri P. Tackling the hepatitis B disease burden in India. J Clin Exp Hepatol 2014;4:312-9.  Back to cited text no. 1
    
2.
Tandon BN, Acharya SK, Tandon A. Epidemiology of hepatitis B virus infection in India. Gut 1996;38 Suppl 2:S56-9.  Back to cited text no. 2
    
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Sabu George D. Long term renal allograft survival with active hepatitis b infection in a sibling-to-sibling transplant recipient: A case report. J Infect Dis Immune Ther 2017;1.  Back to cited text no. 3
    
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Cholongitas E, Tziomalos K, Pipili C. Management of patients with hepatitis B in special populations. World J Gastroenterol 2015;21:1738-48.  Back to cited text no. 4
    
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Yap DY, Chan TM. Evolution of hepatitis B management in kidney transplantation. World J Gastroenterol 2014;20:468-74.  Back to cited text no. 5
    
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Patel BB, Lipka S, Shen H, Davis-Yadley AH, Viswanathan P. Establishing the link between hepatitis B virus infection and colorectal adenoma. J Gastrointest Oncol 2015;6:492-7.  Back to cited text no. 6
    
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Media H. Hepatitis B patients may have increased risk of colorectal, cervical cancers. Infect Dis Advis 2019. Available from: https://www.infectiousdiseaseadvisor.com/home/topics/gi-illness/hepatitis/hepatitis-b-patients-may-have-increased-risk-of-colorectal-cervical-cancers/. [Last accessed on 2020 Mar 20].  Back to cited text no. 7
    
8.
Yap DY, Tang CS, Yung S, Choy BY, Yuen MF, Chan TM. Long-term outcome of renal transplant recipients with chronic hepatitis B infection-impact of antiviral treatments. Transplantation 2010;90:325-30.  Back to cited text no. 8
    
9.
Washer GF, Schröter GP, Starzl TE, Weil R 3rd. Causes of death after kidney transplantation. JAMA 1983;250:49-54.  Back to cited text no. 9
    
10.
Veroux M, Ardita V, Corona D, Giaquinta A, Ekser B, Sinagra N, et al. Kidney transplantation from donors with hepatitis B. Med Sci Monit 2016;22:1427-34.  Back to cited text no. 10
    
11.
Huprikar S, Danziger-Isakov L, Ahn J, Naugler S, Blumberg E, Avery RK, et al. Solid organ transplantation from hepatitis B virus-positive donors: Consensus guidelines for recipient management. Am J Transplant 2015;15:1162-72.  Back to cited text no. 11
    
12.
Degos F, Lugassy C, Degott C, Debure A, Carnot F, Theirs V, et al. Hepatitis B virus and hepatitis B-related viral infection in renal transplant recipients. A prospective study of 90 patients. Gastroenterology 1988;94:151-6.  Back to cited text no. 12
    
13.
Mathurin P, Mouquet C, Poynard T, Sylla C, Benalia H, Fretz C, et al. Impact of hepatitis B and C virus on kidney transplantation outcome. Hepatology 1999;29:257-63.  Back to cited text no. 13
    
14.
Parfrey PS, Forbes RD, Hutchinson TA, Beaudoin JG, Dauphinee WD, Hollomby DJ, et al. The clinical and pathological course of hepatitis B liver disease in renal transplant recipients. Transplantation 1984;37:461-6.  Back to cited text no. 14
    
15.
Pirson Y, Alexandre GP, Ypersele C. Long-term effect of HBs antigenemia on patient survival after renal transplantation. N Engl J Med 1977;296:194-6.  Back to cited text no. 15
    
16.
Perrillo RP. Hepatitis B and renal transplantation: Securing the sword of damocles. Hepatology 2002;36:1041-5.  Back to cited text no. 16
    
17.
Parikh A. Phase 2 Study of Lamivudine in Patients with p53 Mutant Metastatic Colorectal Cancer; 2017. Available from: https://clinicaltrials.gov/ct2/show/NCT03144804. [Last accessed on 2020 Mar 20].  Back to cited text no. 17
    
18.
Preda CM, Baicus C, Negreanu L, Tugui L, Olariu SV, Andrei A, et al. Effectiveness of entecavir treatment and predictive factors for virologic response. Rev Esp Enferm Dig 2014;106:305-11.  Back to cited text no. 18
    
19.
Merchea A, Shahjehan F, Croome KP, Cochuyt JJ, Li Z, Colibaseanu DT, et al. Colorectal cancer characteristics and outcomes after solid organ transplantation. J Oncol 2019;2019:5796108.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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