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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 : 471-473
Recurrent septicemia in a renal transplant recipient

1 Nephrology Department, Hashemi Nejad Medical Center, Iran University of Medical Sciences, Tehran, Iran
2 Nephrology Department, Shahed University, Mustafa Khomeini Hospital, Tehran, Iran

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The incidence of infection is significantly elevated in renal transplant recipients,but native kidney infection is an uncommon event in these patients. We describe a 52-year-old renal transplant recipient with infection of the native kidneys that had atypical clinical presentation and a unusual course.

Keywords: Renal transplantation, Urinary tract infections, Mixed infections

How to cite this article:
Nejad-Gashti H, Sanavi S, Afshar R. Recurrent septicemia in a renal transplant recipient. Saudi J Kidney Dis Transpl 2009;20:471-3

How to cite this URL:
Nejad-Gashti H, Sanavi S, Afshar R. Recurrent septicemia in a renal transplant recipient. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2021 May 12];20:471-3. Available from: https://www.sjkdt.org/text.asp?2009/20/3/471/50783

   Introduction Top

Incidence of infection is significantly higher in renal transplant recipients than general popula­tion. transplant recipients have several defects in immune system that result in decreased host re­sistance to infection. [1] Urinary tract infections (UTIs) are the most common bacterial infections that occur in renal transplant recipients, parti­cularly in the first few months post transplant. [2] However, native kidney infection occurs rarely and this may mislead the physician mostly be­cause of their little role in urine production. 1 Moreover, due to low glomerular filtration and renal uptake of the native kidneys, interpreta­tion of diagnostic methods such as radionuclide methods is difficult. [3]

We present a renal transplant recipient patient with prolonged fever complicated consecutive infections with different etiology and unusual source.

   Case Report Top

A 52-year-old man suffered from chronic re­nal failure (CRF) of unknown etiology and had been maintained on hemodialysis therapy for five years before he received a living unrelated kidney transplant. He complained of fever and malaise without any other problem.

On physical examination the patient's oral tem­perature was 38.5°C, the transplanted kidney, urine output, and other systems were unre­markable. The chest x-ray and laboratory fin­dings including urinalysis, BUN, and serum creatinine were within normal limits. Blood and urine cultures were negative [Table 1]. The titer of CMV IgM antibody was elevated and PCR study of CMV antigen revealed positive particles. Ultrasonography revealed small multi­cystic native kidneys and normal allograft.

The patient was originally on triple immuno-suppressive therapy that included cyclosporine 100 mg twice daily, azathioprine 50 mg daily, and prednisolone 5 mg daily. Azathioprine was discontinued and empiric intravenous gancy­clovir was initiated and continued for 1 month. The fever subsided within 5 days and oral pre­paration of the drug was administered for the following two months.

The patient was discharged with good general condition on outpatient clinic visit at the end of the first month. However, after 2 months, the patient was referred again for severe fever and shaking chill. On physical exam, he looked toxic and ill with oral temperature of 39°C. Blood and urine cultures and CMV antigen and antibody assays were requested, and empiric broad spec­trum antibiotic therapy was initiated. The cul­tures were negative, and the CMV assays were within normal limits. Unfortunately, the patient remained febrile despite the administration of broad spectrum antibiotics, and even after mo­difying them. The bone marrow culture was also negative and repeated ultrasonography showed the same findings as the previous one.

The renal function tests remained normal du­ring hospitalization. A Gallium-67 citrate scan revealed low uptake of gallium in lower and posterior portions of the liver, which had normal size and function.

Overall, with these findings we concluded that the right small native kidney might be infected as an occult site of infection. The patient was sche­duled for urgent surgical exploration, which re­vealed a severely infected right kidney and was excised. Two days after the surgical resection, the patient expired because of severe septicemia.

   Discussion Top

Infection remains a significant cause of morbidity and mortality in renal transplant reci­pients. [4] However, infections in patients with long-term successful allografts are typically si­milar to those that develop in the general population. [5]

Factors that confound the diagnosis of infection in the renal recipient include delays in clinical diagnosis due to modified clinical and radiolo­gical signs in the immunocompromised hosts, multiple antibiotic courses, inherent diagnostic uncertainty due to a preceding CMV infection, and involvement of extra-allograft sites, [6] as what happened in our patient who developed infec­tion in the native kidneys. In renal recipient pa­tients, infections of the native kidneys occur ra­rely because of low renal blood flow, renal fib­rosis, and low urine output unless urine stasis is detected such as in cysts similar to this pa­tient, [7] who also suffered from a recent and pro­longed CMV infection that was another pre­disposing factor.

The diagnosis of infection in the native kidney was complicated because of the low kidney up­take of gallium and the need for nephrectomy, which was a high risk surgical operation in an ill patient with probable eventual loss of the trans­planted kidney. Moreover, the late diagnosis of the source of infection may result in a prolonged recovery period and antibiotic resistance. UTIs developing more than three to six months post transplant, are considered more benign than early ones. [8] How-ever, some evidence suggests that late UTIs are not necessarily benign and may be associated with an increased risk of mortality as was found in one large retros­pective cohort study. [9]

   References Top

1.Danovitch Danovitch GM. Handbook of kidney transplantation. 4th ed. Philadelphia, LW & W, 2005;10:279-332.  Back to cited text no. 1    
2.Rubin RH. Infectious disease complications of renal transplantation. Kidney Int 1993;44:221.  Back to cited text no. 2  [PUBMED]  
3.Brenner BM. The Kidney. 8 th ed, Philadelphia: Saunders; 2008.27:877.  Back to cited text no. 3    
4.Rao KV, Andersen RC. Long-term results and complications in renal transplant recipients: Observations in the second decade. Transplantation 1988;45:45.  Back to cited text no. 4  [PUBMED]  
5.Fishman JA, Rubin RH. Infections in organ­transplant recipients. N Engl J Med 1998;338: 1741-51.  Back to cited text no. 5  [PUBMED]  [FULLTEXT]
6.Meier-Kriesche HU, Friedman G, Jacobs M, et al. Infectious complications in geriatric renal transplant patients. Transplantation 1999;68: 1496-502.  Back to cited text no. 6  [PUBMED]  [FULLTEXT]
7.Lyerova L, Lacha J, Skibova J, et al. Urinary tract infection in patients with urological complications after renal transplantation with respect to long-term function and allograft survival. Ann Transplant 2001;6:19.  Back to cited text no. 7    
8.Grekas D, Thanos V, Dioudis C, et al. Treat­ment of urinary tract infections with ciproflo­xacin after renal transplantation. Int J Clin Pharmacol Ther Toxicol 1993;31:309.  Back to cited text no. 8  [PUBMED]  
9.Abbott KC, Swanson SJ, Richter ER, et al. Late urinary tract infection after renal trans­plantation in the United States. Am J Kidney Dis 2004;44:353.  Back to cited text no. 9  [PUBMED]  [FULLTEXT]

Correspondence Address:
Reza Afshar
Mustafa Khomeini Hospital, Italia St, Postal Code 14166435185, Tehran
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PMID: 19414955

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