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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 1996  |  Volume : 7  |  Issue : 4  |  Page : 398-400
An Unusual Cause of Recurrent Bacteriuria in a Kidney Transplant Recipient


Division of Nephrology and Renal Transplantation, King Fahad National Guard Hospital, Riyadh, Saudi Arabia

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   Abstract 

A 17-year old Saudi male presented to the transplant clinic of the King Fahad National Guard Hospital, Riyadh two weeks after undergoing a living unrelated kidney transplant in India. Graft function was normal and routine urine culture grew Pseudomonas aeruginosa for which he was treated; a follow-up urine culture was negative. Five months later, routine urine culture again documented the presence of Pseudomonas while the patient continued to be asymptomatic with normal graft function. Abdominal ultrasound showed shrunken native kidneys and a normal graft. A slightly echogenic mass was detected in the bladder. Cystocopy showed a retained non­absorbable suture at the area of the uretero-vesical anastomosis. Cystoscopic removal of the suture was carried out following which urine cultures have remained persistently negative.

Keywords: Urinary tract infection, Renal transplantation, Intravesical foreign body, Asymptomatic bacteriuria.

How to cite this article:
Al Khudair W, Abu-Romeh S, Mansi M K, Huraib S. An Unusual Cause of Recurrent Bacteriuria in a Kidney Transplant Recipient. Saudi J Kidney Dis Transpl 1996;7:398-400

How to cite this URL:
Al Khudair W, Abu-Romeh S, Mansi M K, Huraib S. An Unusual Cause of Recurrent Bacteriuria in a Kidney Transplant Recipient. Saudi J Kidney Dis Transpl [serial online] 1996 [cited 2020 Jan 21];7:398-400. Available from: http://www.sjkdt.org/text.asp?1996/7/4/398/39412

   Introduction Top


Urinary tract infection (UTI) is a common complication following kidney transplantaion. The incidence of UTI reaches as high as 50% among recipients in the first three months post­transplant [1] . Asymptomatic bacteriuria post­transplant is usually associated with anatomical for physiological abnormalities in the urinary tract of therecipient. Iatrogenic retention of intravesical foreign bodies, e.g., stents, non-absorbable sutures or catheter parts are known causes of persistent bacteriuria and recurrent UTI in routine urologic practice [2],[3] . However, this is seldom reported in kidney transplant recipients. We describe a case of a retained non-absorbable suture in the urinary bladder as a cause of recurrent asymptomatic bacteriuria in a kidney transplant recipient.


   Case Report Top


A 17-year old Saudi male presented to the renal transplant unit of the King Fahad National Guard Hospital, Riyadh two weeks after undergoing a living unrelated renal transplant in India. End-stage renal disease was secondary to focal segmental glomerulo­sclerosis. Physical examination showed that the patient was afebrile and there was no tenderness over the graft or the suprapubic area. Laboratory investigations including complete blood count, liver function tests, and renal profile, were all within normal limits. Urinalysis revealed excess pus cells and urine culture grew  Pseudomonas aeruginosa Scientific Name Search nsitive to amikacin, ceftazidime and piperacillin and resistant to gentamicin and quinolones. Ultrasonography and dop-pler studies were performed on the graft and were reported to be normal. Native kidneys were present and small in size, typical of end-stage kidneys.

The patient was given ceftazidime intravenously for 10 days and was discharged from the hospital. Subsequent regular follow­up visits to the out-patient department showed a persistently normal functioning graft and negative urine cultures. However, urinalysis showed persistent pyuria of 10-20 white cells per high power field. Five months post­-transplantation, while on a routine follow-up visit, the urine culture was positive for Pseudomonas aeruginosa with the same pattern of antibiotic sensitivity as earlier. The patient was asymptomatic and physical examination showed that he was afebrile, with no tenderness over the graft, suprapubic or the flank areas.

The patient was hospitalized and started on intravenous ceftazidime. Repeat ultrasono­raphy showed no change in graft or native kidneys; however, a mass was seen protruding from the right wall of the bladder [Figure - 1]. An abdominal X-ray did not show any radio­opacities. Cystoscopic examination showed normal anterior and posterior urethra; also, the native ureteric orifices and trigone were normal in caliber and position. The area of the transplant uretero-vesical anastomosis showed a continuous five zero Proline suture protruding through the muco-sa and covered by encrustation [Figure - 2]. The transplanted ureteric orifice was noted medial to this suture.

The encrustations were removed by grasping forceps and, using scissors forceps, the loops of the suture were cut at the knot and removed cystoscopically. The material was sent for bacteriological examination which grew Pseudomonas aeruginosa. Follow-up urinalysis in the clinic was normal and urine culture has remained persistently negative following removal in the retained suture.


   Discussion Top


Iatrogenic intravesical placement of foreign bodies is a known cause of recurrent UTI in urologic practice. Besides being a nidus for infection, non-absorbable suture material anywhere in the urinary tract can also act as a nidus for stone formation. Most of the patients that have presented to our institution immediately after a living unrelated kidney transplant in India have harbored UTI. In the case described above, the persistence of pyuria and growth of the same strain of infective organism from urine as well as the retained suture led to the discovery of the nidus of infection which was iatrogenic. The reason for using a non-absorbable continuous suture inside the bladder remains uncertain.

A Similar case that was treated by one of the authors is worthy of mention (unpublished data). A patient was transplanted in India and presented to the follow-up center with repeated attacks of Pseudomonas septicemia with a peculiar sensitivity pattern to only imipenem and cilastin. Radiological imaging was not helpful in detersining the source of infection and neither was cystoscopic examination. While correcting a coincidental vesico-ureteric reflux into the transplanted kidney, a non­absorbable suture with encrustation was identified and removed. The Pseudomonas infection was eradicated thereafter.

In conclusion, we wish to draw attention to retained sutures as a peculiar cause of persistent or recurrent bacteriuria in a kidney transplant patient which could be a source of considerable morbidity, if left undiagnosed.

 
   References Top

1.Prat V, Horoickova M, Matousovic K, Hatala M, Liska M. Urinary tract infection in renal transplant patients. Infection 1985;13:207-10.  Back to cited text no. 1    
2.Eckford SD, Persad RA, Brewster SF, Gingell JC. Intravesical foreign bodies: five-year review. Br J Urol 1992;69(l):41-5.  Back to cited text no. 2    
3.Granados EA, Rios GJ, Salvador J. Iatrogenic foreign bodies. A complication in urologic practice. Actas Urol Esp 1991;15(5):425-8.  Back to cited text no. 3    

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Correspondence Address:
Waleed Al Khudair
Division of Nephrology and Renal Transplantation, King Fahad National Guard Hospital, P.O. Box 22490, Riyadh 11426
Saudi Arabia
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PMID: 18417771

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    Abstract
    Introduction
    Case Report
    Discussion
    References
    Article Figures
 

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