CUTANEOUS MANIFESTATION IN RENAL TRANSPLANT RECIPIENTS IN SOUTHERN IRAQ

Forty–eight patients living in southern Iraq with renal transplantation were studied for dematological lesions between Jan. 2001 and Feb. 2002, at Basrah renal transplation followup center. All patients had skin problems of different kinds; Cushingoid features in 85.4%, hair and nail changes in 82%, infections in 20% and tumors in 28%. Among skin infections recalcitrant warts were the most frequent (17%). High incidence of skin cancer was recorded (4.2%) as compared to other Iraqi studies . Kaposi”s sarcoma was not seen during the study period.


Introduction
enal transplantation is frequently the most effective treatment of advanced chronic renal failure 1 .In Iraq, renal transplantation started since the early 1970's.Great expansion in this field was achieved after 1990 2 .Renal transplantation requires prolonged use of immunosuppressive agents that may result in various complications including skin involvement.In fact, previous studied that have dealt with this problem all recorded high frequency of dermatological lesions in renal transplant recipient.Bencini et al in 1983 described cutaneous manifestations among 105 patients; namely they noticed that 55% were iatrogenic, 74% infectious, 12% precancerous while 4% were miscellaneous 3 .The latest Iraqi study in this field was conducted in 1998 on 80 renal transplant recipients and reported similar findings albeit with lower incidence of skin cancer 4 .The purpose of this study was to focus on the cutaneous complications of immunosuppressive therapy among renal transplant recipients who live in the southern part of Iraq and to compare the findings with other studies.

Patients and methods
Between January 2001 and February 2002, Forty-eight patients with renal transplantation on immunosuppressive therapy were included in the study.They R all lived in the southern part of Iraq and were attending Basrah renal transplantation follow-up center regularly.The immunosuppressive regimen consisted of either double therapy (Azothioprine or Cyclosporine plus prednisolone) or triple therapy (Azathioprine 100-150mg day and prednisolone 10-30mg/day).Detailed information regarding age, sex, duration of transplantation and type of immunosuppressive drugs were obtained for each patient.Relevant investigations such as complete blood picture, serum creatinine, and sometimes ultrasonic examination were done.Any suspicious skin lesion was biopsied and sent for histopathological examination.During the study period, all patients had functioning renal grafts with no evidence of rejection.For the purpose of studying early and late effects of immunosuppressive therapy, the incidence of skin manifestations before and after 6 months following transplantation was calculated.

Results
Forty-eight patients with renal transplantation were seen with age range from 17-61 years (mean =39.2 years), 36 (75%) were males and 12 (25%) were females.Twenty-five (52%) patients received their kidney grafts from liverelated donors.The majority of warts occurred in the late post-transplantation period.Extensive tinea versicolor was seen in 6 patients.Regarding skin tumors (table V), benign tumors were reported in 25 patients (52%).The majority of them appeared in the late post-transplantation period.Precancerous lesions (solar keratosis) were seen only in 1 patient (2%) while skin malignancy was seen in 2 patients (4.2%).Both cases were pigmented nodulo-ulcerative basal cell carcinomata.

Discussion
The present study clearly demonstrates that cutaneous lesions form a significant problem in renal transplant recipients as all patients showed some kind of skin lesions during the observation period.Obviously, the iatrogenic Cushingoid features were the commonest cutaneous finding, especially in the early posttransplantation period, although there was individual variation in the type and extent of these changes.Previous studies showed that viral warts were the most frequent coetaneous infection 4.5 .We have similarly reported that warts tended to be extensive and resistant to conventional treatment.In transplant patients, human papilloma virus infections may predispose to malignant transformation particularly at genital sites 6 , therefore it is essential to advice these patients for long-term follow-up and close observation to detect early malignant changes.As demonstrated by other studies, high incidence of fungal infections werenoticed (12.5%) owning to the increased colonization of the skin by yeast flora 7 .
It has been documented that renal allorgraft recipients are prone to develop cancer particularly skin malignancy.Such risk is increased as the duration following transpanation is lengthened 8 .However, recent Iraqi studies confirm that our population, including renal allograft recipients, is less predisposed to skin malignancy 4 .We have reported a higher incidence of cancer among renal transplant recipient residing in southern Iraq as compared to other studies 4,11 .This may be attributed to the overall increase in the incidence of skin cancer in the population living in southern Iraq involving relatively younger age groups, particularly during the last decade 10 .Although Kaposi's sarcoma was considered as the most common tumor after renal transplantation in neighboring countries 12,13 , we didn't record this tumor in our patients during the study period .This may be explained partly by the rarity of Kaposi's sarcoma in Iraq.However, extension of the observation period with inclusion of larger number of patients is required to clarify the actual incidence of Kaposi's sarcoma in renal transplant recipients.In conclusion, cutaneous complications of immunosuppressive therapy are frequent in renal transplant recipients, and require close dermatological surveillance, especiallly in those who survive long with the renal graft.

Table I : types of cutaneous manifesta- tions in renal transplant recipients
Clinically, all patients had different kinds of skin manifestations during the study period (TableI).There were Cushingoid features in 40 pts (85.4%),