Document Type

Conference Proceeding

Publication Date


Publication Title

J Gen Intern Med


CASE: 39 year old female with a history of left nephrectomy in 2009, end-stage renal disease due to obstructive uropathy from neurogenic bladder, status post kidney transplant in 2016 with subsequent failure in 2020. She started peritoneal dialysis that year. She had residual urine production, for which she used intermittent straight catheterization. She was admitted for severe symptomatic anemia. Vitals were within normal limits. The examination was remarkable for subtle pain in the right lower quadrant. Complete blood count revealed a white count of 14.2 and hemoglobin of 6.0 mg/dL. Incidentally, the nursing staff noted cloudy urine with a very dense consistency during her straight catheterization. Dipstick urinalysis was unable to be fully processed due to the dense consistency of her urine but showed 149 RBCs, 182 WBCs, and many bacteria. Computed Tomography Abdomen showed a 7 cm large gas and fluid collection with no normal identifiable renal parenchyma consistent with necrosis of her kidney allograft. Abscess culture grew Actinomyces species and she was started on Ertapenem. The transplant surgery team was consulted but did not recommend transplantectomy due to poor surgical candidacy. A percutaneous drain was placed to achieve source control. She was eventually discharged with long-term oral antibiotic therapy with Augmentin. IMPACT/DISCUSSION: 1 in 5 patients with renal transplantation will have allografts that fail in 5 years, and more than one in two will have graft failure by 10 years. Potential complications of failed allografts include infections, malignancy, bone disease, and cardiovascular disease. Among these, infections remain the leading cause of complications following a kidney transplant. These can occur early post-transplant, during peak immunosuppression, and late onset. The latter occurs 6-12 months following transplant and includes community-acquired pneumonia, upper respiratory infections, and urinary infections, which are by far the most common. In patients with urinary infections, the clinical presentation can range from asymptomatic bacteriuria or pyuria to pyelonephritis and sepsis. In patients with failed transplants and recurrent urinary tract infections or sepsis, transplantectomy should be considered. This patient had multiple previous episodes of pyelonephritis with positive cultures for ESBL and VRE organisms. Patient could not recall if transplantectomy was discussed during her prior infection episodes. Her presentation was subtle despite the large abscess in the graft. This patient's symptoms were initially attributed to severe anemia and she did not exhibit any clear infectious symptoms. CONCLUSION: This case illustrates potential infectious complications of a failed kidney allograft. Transplantectomy should be discussed in patients with failed allograft and recurrent bacterial infections, and immunosuppression should be weaned accordingly. Diagnosis of renal allograft complications can be challenging due to atypical or subclinical presentations.




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