Fungal culture, CMV PCR, and BK virus PCR should be considered in a patient who does not improve despite appropriate antibiotic coverage. Hematuria should raise concern for BK virus7 and adenovirus. BK virus should be considered when treating patients on high doses of immune suppression, as there is an association between this infection and graft failure.7 Rarely, MTB can cause AGP.8
Empiric antibiotic coverage includes broad-spectrum antibiotics against gram-negative enteric organisms, including Pseudomonas aeruginosa, and gram-positive organisms, including Enterococcus species. Although optimal duration of antibiotics for AGP is unknown, most nephrologists treat graft pyelonephritis due to a bacterial etiology for 10 to 14 days.1 Complications include poor graft outcome and decreased long-term survival.
Adenovirus infection in a renal transplant patient is uncommon and typically presents with hemorrhagic cystitis. In rare cases, this infection can cause disseminated infection. Management is mostly supportive. Reduction of immunosuppression may be associated with viral clearance.9 Cidofovir and intravenous immune globulin may be considered for patients with life-threatening adenovirus infection10; however, there are no large trials that show a clear benefit for patients with AGP due to adenovirus.
Our patient’s urinary symptoms and fever resolved after 1 week of hospitalization with supportive measures and a reduction in immunosuppression, namely a reduction of the dosing of mycophenolate mofetil and tacrolimus. (Optimal changes in the dosing of immunosuppressive agents should be carried out under consultation with a transplant nephrologist.) However, our patient’s creatinine remained elevated at 1.5 mg/dL. Given the low suspicion for graft rejection, biopsy of the kidney transplant was not performed. He returned to the nephrology clinic 3 months later with an improved creatinine of 1.1 mg/dL.
THE TAKEAWAY
Fever and urinary symptoms in a renal transplant patient suggest either graft pyelonephritis or graft rejection. In addition to the usual gram-negative enteric organisms associated with pyelonephritis in a patient with native kidneys, clinicians should consider low-virulence gram-positive organisms, viruses, fungi, and mycobacteria as potential etiologies. The risks and benefits of reducing or discontinuing immunosuppressive medications in the setting of AGP should be discussed with a nephrologist.
CORRESPONDENCE
Pruthul Patel, MD, Los Angeles County + University of Southern California Medical Center, IRD Building, 2020 Zonal Ave, Rm. 115 Los Angeles, CA 90033; pruthulp@usc.edu