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Saudi Journal of Kidney Diseases and Transplantation
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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 3  |  Page : 458-461
Intractable urinary tract infection in a renal transplant recipient


Department of Nephrology, St. John’s Medical College Hospital, Bangalore, India

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   Abstract 

Urinary tract infections (UTI) are the most common bacterial infections after renal transplantation and are associated with significant morbidity and mortality. Recurrent or relapsing infections are not uncommon in the early post-transplant period and superadded fungal UTI can occur in these patients, posing a difficult therapeutic problem. Literature on recurrent UTI after transplant as well as the ideal approach to such patients is scanty. We present the case of a renal al­lograft recipient who presented with relapsing bacterial UTI complicated by systemic fungemia; also, a brief review of fungal UTI is attempted.

Keywords: Recurrent urinary tract infection, C. glabrata, Voriconazole, Nephrectomy

How to cite this article:
Satish R, Gokulnath. Intractable urinary tract infection in a renal transplant recipient. Saudi J Kidney Dis Transpl 2009;20:458-61

How to cite this URL:
Satish R, Gokulnath. Intractable urinary tract infection in a renal transplant recipient. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2020 Nov 29];20:458-61. Available from: https://www.sjkdt.org/text.asp?2009/20/3/458/50779

   Introduction Top


Urinary tract infection (UTI) is the most common bacterial infection occurring in the post transplant period, particularly in the early post transplant stage. UTI is associated with significant morbidity, whether it occurs in the first few months after transplantation or develops in the late post transplant period (> 6 months). Recurrent UTI is the recurrence of infection within two weeks of completion of antimicro­bial therapy. A thorough evaluation of the uri­nary tract to look for anatomic abnormalities, appropriate antibiotic therapy and continued prophylaxis is advisable in patients with recur­rent UTI. Superadded fungal UTI is not uncom­mon in patients with recurrent UTI and invasive fungal infection of the kidney is difficult to treat. Literature on recurrent UTI after trans­plant and the ideal approach to such patients is scanty. We present a renal allograft recipient with recalcitrant bacterial and complicating fungal UTI, with a brief review of fungal UTI.


   Case Report Top


A 23 year old male patient presented to us in July 2006 with advanced renal failure and uremic symptoms. He had not had any prior medical evaluation and did not have any history of re­peated UTI in childhood, no dysuria or voiding difficulty, though the urinary volume had reduced of late. On examination, he was malnourished, anemic and mildly dyspneic at rest. The pulse rate was 98 per min and blood pressure was 170/90 mmHg. Cardiovascular examination re­vealed loud S1, no pericardial rub or gallop rhy­thm and respiratory system examination revealed bilateral basal crepitations. Abdominal exami­nation did not reveal any abnormalities and the external genitalia were normal. Investigations done revealed hemoglobin of 8.6 gm/dL, total WBC count of 6700/cu mm with normal diffe­rential count and platelet count of 1.1 lakh/cu mm. Blood urea was 213 mg/dL, serum create­nine was 8.6 mg/dL, sodium was 134 meq/L, potassium was 4.7 meq/L and chloride was 101 meq/L. Liver function tests were normal. Urine analysis revealed 3 + protein, 3-5 RBC per HPF and 10-12 WBC per HPF. Culture of two mid­stream urine samples grew Escherechia coli with colony count of 105 per mL sensitive to first line antibiotics. Ultrasound of the abdomen re­vealed a single contracted ectopic pelvic kidney on the right side measuring 7.5 × 2.2 cms; the left kidney was not visualized. A computerized tomographic scan of the abdomen also failed to localize the left kidney and an MCU done did not reveal any active vesico ureteral reflux.


   Course in the Hospital Top


The patient was hemodialyzed initially though a temporary internal jugular catheter and eva­luated for a living related kidney transplant, mother being his donor. He was treated for UTI with 10 days of oral ciprofloxacin three months prior to transplant and the pre-transplant urine and blood cultures were negative. He underwent kidney transplantation on 1/12/2006 and had a smooth post-operative course with brisk diuresis and the serum creatinine reached a nadir of 0.6 mg/dL by the fifth post operative day. He was started on conventional immunosuppression with prednisolone, cyclosporine and azathioprine in view of HLA haplomatch. On the eighth post operative day, he developed high fever with chills. He had leukocytosis with a total white cell count of 14,700 per cu mm and differential count showed 89% polymorphs, 9% lymphocytes and 2% band forms. Blood and urine cultures grew E. coli. His graft functions had worsened, with serum creatinine of 2.6 mg/dL, although he was non oliguric. Graft Doppler revealed good anastomotic flow with no evidence of uri­nary tract obstruction and the ureteric stent was found in-situ. A diagnosis of gram negative bacteremia secondary to UTI, was made and the patient was treated with cepaperazone sulbactam for a total period of 21 days and the ureteric stent was removed. At discharge, the serum creatinine was 1.1 mg/dL and the urine culture after the course of antibiotic therapy was nega­tive. He was put on antibiotic prophylaxis with trimethoprim-sulfamethoxazole. One week later, he presented with high grade fever and serum creatinine of 2.1 mg/dL. Blood culture was negative for bacteria and fungus, while urine culture grew E. coli. Chest radiograph was nor­mal. CMV IgM antibody was negative. The cause of recurrent UTI was evaluated; no additional information was obtained. He res­ponded to treatment with the same antibiotic and both the patient and graft functions showed improvement. He presented to us again one month later with a history of high grade fever associated with chills, of two days duration. At admission, his blood pressure was 90/60 mm Hg; pulse was feeble, temperature was 103°F; however, systemic examination was non con­tributory. He was admitted to the ITU with a presumed diagnosis of gram negative septi­cemia. Urine and blood cultures at this time grew Candida glabrata. His graft functions had again worsened and serum creatinine was 8.0 mg/dL. In view of systemic candidemia, intra­venous amphotericin B was started along with Ticarcillin Sulbactam. He was non-oliguric and was managed conservatively. At the end of the first week after hospitalization, the graft func­tions had improved with a drop in creatinine to 3.5 mg/dL and the 24 hour urine output being 1.5 liters. He could not tolerate amphotericin B and developed repeated episodes of generalized seizures. A blood chemistry including calcium, magnesium, phosphorus levels was normal and CT scan of the brain as well as CSF analysis did not reveal any intra-cerebral pathology. Anti-fungal therapy was changed to intravenous voriconazole. He also had hyperglycemia, which was controlled with insulin infusions. Immu­nosuppression was slightly reduced given the life threatening nature of the infection. A deci­sion was taken to perform a native kidney ne­phrectomy in view of the relapsing nature of the infection, although no definite evidence of in­fection had been found in the native kidney. He tolerated the surgery well, his general condition improved and the serum creatinine reached a baseline of 1.2 mg/dL. He received a total of 21 days treatment with voriconazole and at the end of therapy, blood fungal culture was negative. Histopathology of the nephrectomy specimen revealed evidence of chronic pyelonephritis. Also, no active neutrophilic infiltrates or fungal elements were noted. After discharge, he came for follow-up once after two weeks and was keeping fine. He then traveled to his native town where he apparently developed fever and succumbed to the illness before he could be brought to the hospital. No postmortem was done and the exact cause of death could not be ascertainned.


   Discussion Top


Urinary tract infection is the most common bacterial infection occurring in renal transplant recipients and is seen in 30-40% of recipients [1] during the first four months after transplan­tation. The majority of organisms cultured are Gram negative (76%) with approximately 33% being caused by E.coli and 20% by Enteroco­ccus and Klebsiella enterobacter. [2] The major risk factors for UTI after renal transplantation include in dwelling bladder catheters, handling and trauma to the kidney and ureter during sur­gery, anatomic abnormalities of the native or transplanted kidneys (such as vesicoureteral re­flux, calculi or stents), neurogenic bladder espe­cially in diabetic patients and possibly, rejection and immunosuppression. [3],[4],[5],[6],[7]

UTI in the early post transplant period is asso­ciated with significant graft dysfunction and re­lapse. [1] The morbidity associated with UTI ap­pears to be related to the time of occurrence of the infection after transplantation. Infections occurring in the hospital are more serious with bacteremia occurring in approximately 10% and graft infection in 90% of recipients and these infections may be associated with allograft dys­function and may predispose to development of acute rejection. Recurrence or re-infection occurs often with one study reporting a relapse rate of 73% in the early post-transplant period. [8]

The pre-transplant urine culture was negative in our patient; however, he had three episodes of UTI in the first month after transplant. These episodes were associated with significant graft dyfunction, which recovered once the infection was controlled. We did not perform graft biopsy in our patient, since graft functions improved with antibiotic therapy thus ruling out acute re­jection.

Fungal UTI represents a high-risk event in cri­tically ill patients. A prospective multi-centre surveillance study of 861 hospitalized patients identified risk factors such as prior antibiotic therapy (90%), urinary tract pathology (38%), urinary tract devices (83%), diabetes (39%) and malignancies (22%), for the development of fun­gal infections.

Our patient had received three prolonged cour­ses of antibiotic therapy thus, predisposing him to superadded fungal infection. Invasive fungal infections contribute significantly to patient mor­bidity and mortality after transplantation and an incidence of 2.3-3.5% has been observed. [9],[10] Over 60% of systemic fungal infections are due to Candida species with Candida albicans being the most common organism. Prolonged fever not responding to antibiotic therapy is the com­monest clinical situation and a high index of suspicion is necessary. Data from the US Renal Data System found that the majority of fungal infections occurred in the first six months post­transplant (66%) and by logistic regression analysis, it was seen that end stage renal disease due to diabetes, duration of pre-transplant dia­lysis, maintenance tacrolimus and allograft re­jection were associated with an increased risk of developing fungal infections. [11] Recipients who had developed fungal infections had a relative risk of mortality of 2.88 when compared to other recipients. Other studies have also found a high mortality rate of 75%. [9]

The most common antifungal agents used cur­rently for the treatment of Candidemia are am­photericin B, fluconazole and caspofungin. The choice of agent is guided by the hemodynamic stability of the patient, history of prior exposure to antifungals and the infecting Candida species. Many C. glabrata strains are resistant to fluco­nazole and they respond less well to therapy. The guidelines of the Infectious Disease So­ciety of America (IDSA) recommend avoiding the use of fluconazole for the treatment of C. glabrata. [12] Amphotericin B remains, therefore, the drug of choice though caspofungin is now preferred due to its better safety profile. Intra­venous or oral voriconazole has been recom­mended for the treatment of invasive asper­gillosis, disseminated infections caused by Can­dida species and in patients who are refractory to, or intolerant to, other antifungal therapy. [12],[13] The appropriate duration of therapy for candi­demia has not been widely studied. Serial blood cultures are advised and two weeks of therapy after blood cultures become negative has been advocated.

Certain issues are intriguing in this patient and this case is being presented to highlight a rather uncommonly encountered problem in clinical practice. The native diseased kidney can be a source of persistent infection and was hence removed in this patient. Despite this, he con­tinued to have relapsing infection. The histo­pathology of the nephrectomy specimen also did not show any fungal elements. Though the final cause of death in this case remains un­known, we believe that metastatic abscesses could have led to the recurrence of infection and ultimate death of the patient.

 
   References Top

1.Tolkoff-Rubin NE, Cosimi AB, Russel PS, Rubin RH. A controlled study of trimethoprim­sulfamethaxazole prophylaxis of urinary tract infection in renal transplant recipients. Rev Infect Dis 1982;4(2):614-8.  Back to cited text no. 1    
2.Takai K, Tollemar J, Wilczek HE, Groth CG. Urinary tract infections following renal trans­plantation. Clin Transplant 1998:12(1):19-23.  Back to cited text no. 2    
3.Rubin RH. Infectious disease complications of renal transplantation. Kidney Int 1993;44(1): 221-36.  Back to cited text no. 3    
4.Rubin RH, Wolfson JS, Cosimi AB, Tolkoff­Rubin NE. Infections in the renal transplant recipient. Am J Med 1981;70:405-11.  Back to cited text no. 4  [PUBMED]  
5.Lyerova L, Lacha J, Skibova J, Teplan V, Vitko S, Schuck O. Urinary tract infection in patients with urological complications after renal trans­plantation with respect to long-term function and allograft survival. Am J Transplant 2001;6 (2):19-20.  Back to cited text no. 5    
6.Wilson C, Bhatti A, Rix D, Manas D. Routine intraoperative ureteric stenting for kidney trans­plant recipients. Cochrane Database Syst Rev 2005;4:CD004925.  Back to cited text no. 6    
7.Kauffman CA, Vazquez JA, Sobel JD, et al. Prospective muticentre surveillance study of fungiuria in hospitalized patients: The National Institute for Allergy and Infectious Diseases (NIAID) Mycoses Study Group. Clin Infect Dis 2000;30:14-8.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Alepoulos E, Memmos D, Sakellariou G, Pasc­halidou E, Kyrou A, Papadimitriou M. Urinary tract infections after renal transplantation. Drugs Exp Clin Res 1985;11(2):101-5.  Back to cited text no. 8    
9.Nampoory MR, Khan ZU, Johny KV, et al. Invasive fungal Infections in renal transplant recipients. J Infect 1996;33(2):95-101.  Back to cited text no. 9    
10.Agrawal V, Gupta RK, Jain M. Invasive fungal infections in renal allograft recipients. Indian J Pathol Microbiol 2005;48(4);448-52  Back to cited text no. 10    
11.Abbot KC, Hypolite I, Poropatich RK, et al. Hospitalizations for fungal infections after renal transplantation in the Unites States. Transplant Infect Dis 2001;3(4):203-11.  Back to cited text no. 11    
12.Pappas PG, Rex JH, Sobel JD, et al. Guidelines for the treatment of Candidiasis: Infectious Diseases Society of America. Clin Infect Dis 2004;38(2):161-89.  Back to cited text no. 12    
13.Scott LJ, Simpson D. Voriconazole: A review of its use in the management of invasive fungal infections. Drugs 2007;67(2):269-98.  Back to cited text no. 13    

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Correspondence Address:
Renuka Satish
Department of Nephrology, St. John’s Medical College Hospital, Sarjapura Road, Bangalore
India
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PMID: 19414951

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    Abstract
    Introduction
    Case Report
    Course in the Ho...
    Discussion
    References
 

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