Introduction:
Urinary tract infections (UTIs) pose a significant challenge in the care of renal transplant recipients. Renal transplant recipients face an elevated risk of recurrent UTIs due to immunosuppression, altered urinary tract anatomy and complex comorbidities. Complications of UTIs can lead to graft dysfunction and systemic illness, underscoring the need for effective management. Recurrent urinary tract infections (UTI) are a common clinical problem in kidney transplant recipients. Due to the complex urological anatomy derived from the implantation of the kidney graft, the spectrum of the disease and the broad underlying pathophysiological mechanisms. Recurrent UTI worsen the quality of life, decrease the graft survival and increase the costs of kidney transplantation. The actual published literature on the management of recurrent urinary tract infections is based on case series, observational cohorts and very few clinical trials. Factors such as female sex, old age, history of UTIs, deceased donor, long-term use of an indwelling catheter, diabetes, acute rejection process, use of ureteral stent, abnormal urinary tract anatomy, and hypertension were related to an increased risk of UTIs in kidney recipients. Here we report the management of double renal transplant patient who had recurrent urinary tract infection.
Methods:
33-year-old male patient with history of hypertension, chronic kidney disease (presumed CIN) underwent live related allograft renal transplantation surgery 2015, with no post transplant complication and on triple immunosuppression and doing well on follow ups. After few years, Patient lost to follow up and stopped his immunosuppressive medication by self after which he presented with worsening renal functions which progressed & lead to graft rejection and patient eventually had to be reinitiated on hemodialysis after 5.5 years of 1st renal transplant. Almost 5 years into post renal transplant rejection patient was taken up for 2nd kidney transplant- deceased donor (2023). Post second kidney transplant, patient developed fever and chills and treated with antibiotics for epididymo-orchitis and UTI. But the recovery was short lived and patient had recurrent UTI episodes (with 2 months of second transplant) and during which he received prolonged duration of higher antibiotics for MDR klebsiella pneumonia as grown on culture. Since UTI and fever spikes were persistent, patient underwent cystoscopy and during cystogram it was seen that contrast refluxed into first transplant kidney ureter after which patient was undertaken for sub capsular transplant kidney nephroureterectomy of first transplanted kidney graft with bilateral vasal ligation. Post surgical intervention patient became better and symptom free and no further complications arose in post operative period. Patient is currently under follow up and is doing well.
Results:
33 year old male patient with first renal transplant (live related donor) with non post transplant complications, stopped his immunosuppressive medications on his own, developed chronic allograft rejection (biopsy proven acute cellular rejection) re-initiated on hemodialysis (5.5 years later of first transplant and underwent 2nd renal transplant (deceased donor) in 2023. Post transplant patient improved and discharged on triple immunosuppression with fair graft function developed right epididymo-orchitis and received antibiotics. Yet again patient presented with recurrent episodes of fever spikes and UTI and managed by longer duration of higher antibiotics .He was undertaken for cystoscopy which was essentially normal but a patulous and wide opening of first transplant kidney & ureter, which also showed presence of contrast in same ureter during cystogram. Possibly explaining the source of recurrent episodes of UTI, patient underwent right subcapsular transplant kidney nephroureterectomy (1st transplant kidney and ureter) with immidiate subsidence of fever and rapid symptom improvement. Post surgical intervention patient has improved significantly and doing well on follow up with no signs of further UTI.
Conclusions:
Infection remains an important concern in patients undergoing kidney transplantation. Patient care in the context of life-threatening infections is a great concern. There are many risk factors for urinary tract infection in a kidney transplant patient. There is always a dilemma to balance immunosuppression with recurring infections in such patients. One should keep the horizons wide to find out the actual cause of infection, as in our case primary renal allograft transplant was a source of infection and after removal of the actual source of infection patient recovered & has been doing well till date.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.