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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 1278-1280
Duodenal microbiasis in children on regular hemodialysis

1 Department of Pediatrics, Pediatric Nephrology Unit, Mansoura University Children's Hospital, Mansoura, Egypt
2 Department of Parasitology, Faculty of Medicine, Mansoura University Children's Hospital, Mansoura, Egypt
3 Laboratory Department, Mansoura University Children's Hospital, Mansoura, Egypt

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Date of Web Publication17-Nov-2012

How to cite this article:
El-Refaey AM, Abdelbasset A, Atia G, Matar M, Awad SI, Yahya RS. Duodenal microbiasis in children on regular hemodialysis. Saudi J Kidney Dis Transpl 2012;23:1278-80

How to cite this URL:
El-Refaey AM, Abdelbasset A, Atia G, Matar M, Awad SI, Yahya RS. Duodenal microbiasis in children on regular hemodialysis. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2023 Feb 4];23:1278-80. Available from: https://www.sjkdt.org/text.asp?2012/23/6/1278/103576
To the Editor,

Chronic kidney disease is often associated with depressed cellular and humoral immunity. [1] This clinical state of immunodeficiency results in a higher incidence of infection and morta-lity. [2] Among the common infectious agents in uremic patients, Helicobacter pylori (H. pylori) occurs in 21-64% of end-stage kidney disease (ESKD) [3] and opportunistic parasitic diseases, which may be life threatening (such as Cryptosporidium parvum) [4] and strongyloides stercoralis. [5]

We screened 20 children [8-16 years (10 ± 4.2 years)]; 13 males and seven females) on regular hemodialysis (HD) by a single diagnostic test, enterotest®, for H. pylori and duodenal parasites in order to elucidate their correlation to nutritional status and CD4 counts. All the patients suffered from gastrointestinal symptoms such as dyspepsia and diarrhea. Patients with ongoing inflammatory diseases, diabetes mellitus, immune disorders and those receiving immunosuppressive drugs were excluded from the study. CD4 lymphocytes were counted using flow cytometry (FAS Calibur flow cytometer; Becton Dickinson, USA). Duodenal fluid was studied by enterotest® capsules (HDC Corporation, Mountain View, CA, US) for H. pylori and duodenal parasites. The material extracted was examined for H. pylori by Skirow's medium and christensen urea agar tube (Biomerieux France). Plates and tubes were incubated at 37°C under microaerophillic conditions in a Mc-Intoch jar with addition of microaerophillic package (Oxoid). Isolated colonies were identified by Gram staining, giving Gram negative spiral organism, positive catalase and oxidase test (Oxoid).

Plates and tubes were examined daily for characteristic H. pylori colonies and for urease production for three to five days before being discarded as negative. For the examination of duodenal parasites by direct smear, the acid fast stain was used for Coccidea [6] and Gomori's trichrome stain [7] and Ryan's trichrome stain for Microsporidia. [8]

For stool examination, direct smear, Formol-Ether concentration method [9] and acid fast stain were used for Coccidea, [6] Gomori's trichrome stain [7] and Weber's trichrome stain for Microsporidia [10] and agar plate culture for Strongyloides stercoralis. [11]

H. pylori , C. parvum and I. belli infections were detected in 14%, 16% and 9% of the studied cases, respectively. Infection with H. pylori had a significant positive correlation to CD4 count and negative correlation to serum albumin, nested polymerase chain reaction (nPCR), body mass index (BMI), hemoglobin and duration on HD. C. parvum, Giardia and Isospora had a significant negative correlation to CD4, serum albumin, BMI and hemoglobin, and a positive correlation to the duration on HD. To the best of our knowledge, comparative data of pediatric HD cases are scanty.

H. pylori prevalence was negatively correlated with Kt/V values in our study. Lui et al [12] and Aguilera et al [13] found the same result in a series of adult patients with chronic uremia and on chronic peritoneal dialysis. The positive correlation of H. pylori prevalence to CD4 was reported by Cacciarelli et al [14] and Panos et al, [15] who reported a lower prevalence of H. pylori in patients with CD4 less than 200/μL and suggested a role of CD4 cell and immune function in sustaining H. pylori infection. The negative correlation of H. pylori to hemoglobin may be attributed to its linkage to iron deficiency due to gastrointestinal bleeding. Also, H. pylori has iron receptor on its membrane that could compete with the body for ingested iron, even affecting iron metabolism or absorption, generating a state of chronic iron deficiency. [16] In the current study, there was a negative correlation of H. pylori to time on HD. This finding was also reported by Lopez et al [17] and Nakajima et al, [18] and owed that to a decrease of stomach acid secretion observed in dialysis patients, which might create a more hostile environment for micr organisms. The negative correlation of H. pylori to serum albumin nPCR and BMI could be associated with malnutrition due to anorexia, anemia or bleeding from peptic ulcer. Aguilera et al [13] and Sezer et al [19] reported the same finding.

In the present study, there was a negative correlation of C. parvum, G. lamblia and I. belli to CD4, S. albumin, Hb and BMI, and a positive correlation to duration on HD. Turkcapar et al [4] reported that the prevalence of C. parvum in HD patients was 20%. Seyrafian et al [20] reported that 11.5% of HD patients were infected with Cryptosporidium. Wiwanitkit [21] reported that opportunistic intestinal parasites had a significantly higher prevalence when CD4 was ≤200/μL. The negative correlation of C. parvum, G. lamblia and I. belli to S. albumin, BMI and hemoglobin may be attributed to the malabsorption induced by these protozoan parasites. [22]

In our study, there was a positive correlation of C. parvum, G. lamblia and I. belli to duration on HD. However, Seyrafian et al [20] found no correlation between the prevalence of C. parvum and duration on HD.

Patients with ESKD should be considered as a group at risk for opportunistic parasitic infection. We suggest more studies with controls in order to determine the differences from the general population for the prevalence and treatment response in HD patients.

   References Top

1.Raska Jr K, Raskova J, Shea SM, et al. T cell subsets and cellular immunity in end-stage renal disease. Am J Med 1983;75:734-40.  Back to cited text no. 1
2.Sayarlioglu H, Erkoc R, Demir C, et al. Nutritional status and immune functions in maintenance hemodialysis patients. Mediators Inflamm 2006;2006:20264.  Back to cited text no. 2
3.Rowe PA, el Nujumi AM, Williams C, Dahill S, Briggs JD, McColl KE. Helicobacter pylori infection in uremic patients. Am J Kidney Dis 1992;20:574-9.  Back to cited text no. 3
4.Turkcapar N, Kutlay S, Nergizoglu G, Atli T, Duman N. Prevalence of Cryptosporidium infection in hemodialysis patients. Nephron 2002;90:344-6.  Back to cited text no. 4
5.Adedeji A, Subudhi CP, Hutchison AJ, Burnie JP, Kerr JR. Recurrent Escherichia coli bacteraemia in a patient with chronic renal failure. Nephrol Dial Transplant 2001;16:2429-30.  Back to cited text no. 5
6.Garcia LS, Bruckner DA, Brewer TC, Shimizu RY. Techniques for the recovery and identification of Cryptosporidium oocysts from stool specimens. J Clin Microbiol 1983;18:185-90.  Back to cited text no. 6
7.Gomori G. A rapid one step trichrome stain. Am J Clin Pathol 1950;20:661-3.  Back to cited text no. 7
8.Ryan NJ, Sutherland G, Coughlan K, et al. A new trichrome-blue stain for detection of microsporidial species in urine, stool, and nasopharyngeal specimens. J Clin Microbiol 1993;31:3264-9.  Back to cited text no. 8
9.Richie LS. An ether sedimentation technique for routine stool examinations. Bull. U. S. Army Med Dep. 1948;8:326.  Back to cited text no. 9
10.Weber R. Improved light microscopical detection of Microsporidia spores in stool and duodenal aspirates. N Engl J Med 1992;326:161-6.  Back to cited text no. 10
11.Arakaki T, Hasegawa H, Asato R, et al. A new method to detect Strongyloides stercoralis from human stool. Jpn J Trop Med Hyg 1988;16:11-7.  Back to cited text no. 11
12.Lui SL, Wong WM, Ng SY, Chan TM, Lai KN, Lo WK. Seroprevalence of Helicobacter pylori in Chinese patients on continuous ambulatory peritoneal dialysis. Nephrology 2005;10:21-4.  Back to cited text no. 12
13.Aguilera A, Codoceo R, Bajo MA, et al. Eating behavior disorders in uremia: A question of balance in appetite regulation. Semin Dial 2004;17:44-52.  Back to cited text no. 13
14.Cacciarelli AG, Marano Jr BJ, Gualtieri NM, et al. Lower Helicobacter pylori infection and peptic ulcer disease prevalence in patients with AIDS and suppressed CD4 counts. Am J Gastroenterol 1996;91:1783-4.  Back to cited text no. 14
15.Panos GZ, Xirouchakis E, Tzias V, et al. Helicobacter pylori infection in symptomatic HIV-seropositive and -seronegative patients: A case-control study. AIDS Res Hum Retro-viruses 2007;23:709-12.  Back to cited text no. 15
16.Doig P, Austin JW, Trust TJ. The Helicobacter pylori 19.6-kilodalton protein is an ironcontaining protein resembling ferritin. J Bacteriol 1993;175:557-60.  Back to cited text no. 16
17.Lopez T, Almirall J, Calvet X, et al. Helicobacter pylori does not contribute to iron deficiency in hemodialysis patients. Nefrologia 2006;26:673-8.  Back to cited text no. 17
18.Nakajima F, Sakaguchi M, Amemoto K, et al. Helicobacter pylori in patients receiving long-term dialysis. Am J Nephrol 2002;22:468-72.  Back to cited text no. 18
19.Sezer S, Ibis A, Ozdemir BH, et al. Association of helicobacter pylori infection with nutritional status in hemodialysis patients. Transplant Proc 2004;36:47-9.  Back to cited text no. 19
20.Seyrafian S, Pestehchian N, Kerdegari M, Yousefi HA, Bastani B. Prevalence rate of Cryptosporidium infection in hemodialysis patients in Iran. Hemodial Int 2006;10:375-9.  Back to cited text no. 20
21.Wiwanitkit V. Intestinal parasitic infections in Thai HIV-infected patients with different immunity status. BMC Gastroenterol 2001;1:3.  Back to cited text no. 21
22.Godwin TA. Cryptosporidiosis in the acquired immunodeficiency syndrome: A study of 15 autopsy cases. Hum Pathol 1991;22:1215-24.  Back to cited text no. 22

Correspondence Address:
Ahmed M El-Refaey
Department of Pediatrics, Pediatric Nephrology Unit, Mansoura University Children's Hospital, Mansoura
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.103576

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