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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 1311-1314
Urinary tract infections following renal transplantation: A single-center experience


1 Research Laboratory of Immunology-LR03SP01, Charles Nicoles Hospital, Tunis, Tunisia
2 Department of Nephrology and Laboratory of Renal Pathology-LR00S001, Charles Nicoles Hospital, Tunis, Tunisia
3 Department of Urology, Charles Nicoles Hospital, Tunis, Tunisia

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Date of Web Publication17-Nov-2012
 

   Abstract 

Urinary tract infection (UTI) is the most frequent infectious complication among renal transplant recipients and a frequent cause of bacteremia, sepsis and acute graft failure. To evaluate the incidence, risk factors, type of pathogens and long-term effect of UTIs on graft and patient survivals in our center, we performed a retrospective cohort study reviewing the medical records of patients who received a renal transplant at our center from June 1986 to December 2009, excluding patients who lost their grafts in the first month due to arterial or veins thrombosis and acute antibody-mediated rejection. We studied 393 kidney-transplanted recipients; at least one UTI occurred in 221 (53.69%) patients during the follow-up period. The most frequent pathogens isolated in urine culture were Escherichia coli (n = 39, 18.4%) and Klebsiella pneumonia (n = 31, 14.6%). When patients with UTIs were compared with those without UTIs, female gender and use of mycophenolate mofetil or azathioprine seemed to be risk factors for UTIs on univariate analysis. However, female gender was the only independent risk factor on multivariate analysis RR = 1.964 (1.202-3.207), P = 0.007. This study confirmed that UTIs remain a major problem in renal transplant recipients, and female gender was the only independent risk factor.

How to cite this article:
Barbouch S, Cherif M, Ounissi M, Karoui C, Mzoughi S, Hamida FB, Abderrahim E, Bozouita A, Abdalla T, Kheder A. Urinary tract infections following renal transplantation: A single-center experience. Saudi J Kidney Dis Transpl 2012;23:1311-4

How to cite this URL:
Barbouch S, Cherif M, Ounissi M, Karoui C, Mzoughi S, Hamida FB, Abderrahim E, Bozouita A, Abdalla T, Kheder A. Urinary tract infections following renal transplantation: A single-center experience. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Dec 27];23:1311-4. Available from: http://www.sjkdt.org/text.asp?2012/23/6/1311/103586

   Introduction Top


Urinary tract infection (UTI) is the most frequent infectious complication among renal transplant recipients and a frequent cause of bacteremia, sepsis and acute graft failure. Moreover, previous reports contained conflicting results on the risk factors for UTI after kidney transplantation and on whether UTI may have an effect on graft outcomes. Infectious complications are reported to be the second most cause of death in renal transplanted patient, but UTI have not been implicated in increasing mortality in any study. In previous studies, the risk factors associated with the development of UTI included female gender, age, alterations in the anatomy of the urinary tract, original kidney disease, surgical manipulation during transplantation as well as the dose, intensity and duration of immunosuppression. [1],[2],[3]

We aimed in this study to evaluate the incidence, risk factors, type of pathogens and long-term effect of UTIs on graft function and patient survival in our center.


   Patients and Methods Top


This retrospective cohort study was based on clinical files of patients who received renal transplants in our center from June 1986 to December 2009, excluding patients who lost their graft in the first month because of arterial or vein thrombosis and acute antibody-mediated rejection. All the patients had routine use of a double-J silicon multi-length ureteral stent intraoperatively, and removed at approximately three weeks after transplantation. A urethral catheter was inserted in each patient perioperatively, and was removed within seven days post-transplantation. Every patient received trimethoprim/sulfamethoxazole during the first three months as prophylaxis for UTI and Pneumocystis carini infection. UTI was diagnosed based on a positive urine culture (>100,000 colony-forming units of a pathogenic organism per milliliter of urine) and a consistent urinalysis (positive urinary leukocyte esterase and/or nitrate). Urinalysis with microscopic examination and urine culture were obtained from every renal transplant patient at their routine follow-up visits and when they had clinical symptoms of UTI: dysuria, frequency, fever, suprapubic pain and/or hematuria. Patients with findings suggestive of significant infection were hospitalized for further investigation and treatment, if necessary.


   Statistical Analysis Top


The univariate analysis was performed with chi-square test for categorical variables and Student's "t" test for continuous ones. A multi-variate analysis with logistic regression was performed using a model including all risk factors that showed statistically significant associations or trends in the univariate analysis. P <0.05 was considered significant.


   Results Top


We studied 393 subjects who underwent renal transplantation during the period of the study: 270 (68.7%) men and 123 (31.3%) women, with an average age about 32.8 ± 9.5 years. The mean follow-up time was 92 ± 72.6 months. The mean duration on dialysis was 42.2 ± 39.9 months, 328 patients were on hemodialysis (HD) and 65 on peritoneal dialysis (PD). Three hundred sixteen (80.4%) patients received living donor and 77 (19.6%) deceased donor grafts. There were 340 (87%) patients who received anti-thymocyte globulin (ATG) as induction immunosuppressive therapy. For immunosuppressive maintenance therapy, 240 (61%) patients received cyclosporine A (CsA), 87 (22%) tacrolimus, 144 (37%) azathioprine, 249 (63%) mycophenolate mofetil (MMF) and all (100%) prednisolone. At least one UTI was demonstrated among 221 patients (53.69%) during the follow-up period; 115 patients had one UTI, 49 two UTIs, 24 three UTIs, 15 four UTIs and eight five UTIs. The most frequent pathogens isolated in urine culture were Escherichia coli (n = 39, 18.4%) and Klebsiella (n = 31, 14.6%). Demographic and clinical features on the two groups with and without UTI are illustrated in [Table 1]. When the patients with UTIs were compared with those without UTIs, female gender and use of MMF or azathioprine seemed to be risk factors for UTIs upon univariate analysis. However, female gender was the only independent risk factor on multivariate analyses RR = 1.964 (1.202-3.207), P = 0.007.
Table 1: Demographic and clinical features of the groups.

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   Discussion Top


UTIs are the most common infectious complication post-transplantation. [4] The incidence of UTIs varies from 35% to 79% in various series, [4],[5],[6] and approximately 60% of bacteremia originate from UTIs. [4] In our study, the incidence of UTIs was 53.69% among renal transplanted recipients, which is similar to that reported by other centers. [6] In our study, the most frequent pathogens isolated in urine culture were Escherichia coli (18.4%) and Klebsiella (14.6%), which are similar to several other studies. [6],[7] Risk factors for developing UTIs after kidney transplantation also have varied among studies. The risk factors reported have included female recipient gender, white or black race, deceased donor source of kidney, reflux kidney disease, use of azathioprine or cyclosporine A and early urethral catheter removal. [5],[6],[7] In our study, we found that female gender was the only independent risk factor on multivariate analysis. The cause of higher UTIs in female patients is presumably the shorter urethra and proximity of the urethral opening to the vagina and anus.

After renal transplantation, patients receive immunosuppressive medications to prevent rejection. Some studies have found an association between immunosuppressive drugs and UTIs. [5],[6] However, our results have shown that the use of MMF or azathiaprine are risk factors for UTIs by univariate analysis, but this was not confirmed by multivariate analysis.

In our study, higher serum creatinine levels were noticed at long-term among patients with UTIs, without any statistically significant difference. The effect of UTIs after kidney transplantation on graft and patient survivals is controversial. Some studies reported adverse effects of UTIs on both parameters, [9] whereas other studies did not. [6],[10] In our study, UTIs were not associated with either a deleterious effect on graft function or an increased risk of mortality.

We conclude that UTIs remain a frequent problem after kidney transplantation, and the incidence of UTIs was high in our study. Escherichia coli was the most common cause. There was no increased risk of death. Female gender is an independent risk factor for UTIs.

 
   References Top

1.M, Giuffrida G, Corona D, et al. Infective complications in renal allograft reci-pients: Epidemiology and outcome. Transplant Proc 2008;40:1873-6.  Back to cited text no. 1
    
2.Säemann M, Hörl WH. Urinary tract infection in renal transplant recipients. Eur J Clin Invest 2008;38:58-65.  Back to cited text no. 2
    
3.Sqalli TH, Laboudi A, Arrayhani M, et al. Urinary tract infections in renal allograft recipients from living related donors. Saudi J Kidney Dis Transpl 2008;19:551-3.  Back to cited text no. 3
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4.Dantas SR, Kuboyama RH, Mazzali M, Moretti ML. Nosocomial infections in renal transplant patients: Risk factor and treatment implications associated with urinary tract and surgical site infections. J Hosp Infect 2006;63:117-23.  Back to cited text no. 4
    
5.Chuang P, Parikh C, Langone A. Urinary tract infections after renal transplantation: A retrospective review at two US transplant centers. Clin Transplant 2005;19:230-5.  Back to cited text no. 5
    
6.Takai K, Aoki A, Suga A, et al. Urinary tract infections following renal transplantation. Transplant Proc 1998;30:3140-1.  Back to cited text no. 6
    
7.Alangaden GJ, Thyagarajan R, Gruber SA, et al. Infectious complications after kidney transplantation: current epidemiology and associated risk factors Clin Transplant 2006;20:401-9.   Back to cited text no. 7
    
8.Rabkin DG, Stifelman MD, Birkhoff J, et al. Early catheter removal decreases incidence of urinary tract infections in renal transplant recipients. Transplant Proc1998;30:4314.  Back to cited text no. 8
    
9.Müller V, Becker G, Delfs M, Albrecht KH, Philipp T, Heemann U. Do urinary tract infections trigger chronic kidney transplant rejection in man? J Urol 1998;159:1826-9.  Back to cited text no. 9
    
10.Giral M, Pascuariello G, Karam G, et al. Acute graft pyelonephritis and Long-term kidney allograft outcome. Kidney Int 2002;61:1880-6.  Back to cited text no. 10
    

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Correspondence Address:
Samia Barbouch
Department of Nephrology and Laboratory of Renal Pathology -Lr00S001, Hospital Charles Nicolle, Tunis
Tunisia
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DOI: 10.4103/1319-2442.103586

PMID: 23168875

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    Abstract
   Introduction
   Patients and Methods
   Statistical Analysis
   Results
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    References
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