Five-day fever • elevated creatinine levels • kidney transplant 10 months prior • Dx?

Computed tomography (CT) of the abdomen and pelvis without contrast evaluating for a perinephric or renal abscess was negative. Antibiotic coverage was broadened to meropenem 1 g every 8 hours and vancomycin 1500 mg once, with levels to follow. Repeat urinalysis showed persistent pyuria and worsened hematuria and proteinuria. Urine protein to creatinine ratio was elevated at 1.3 mg/mg. Cystoscopy showed a normal urethra and multiple areas of erythema and edema in the bladder, which was consistent with cystitis.

Fever and urinary symptoms in a renal transplant patient suggest either graft pyelonephritis or graft rejection.

Due to the lack of clinical improvement on broad-spectrum antibiotic coverage, other urinary pathogens, including BK virus, cytomegalovirus (CMV), fungi, and Mycobacterium tuberculosis (MTB), were considered. Serum qualitative polymerase chain reaction (PCR) for BK virus and CMV were negative. Quantitative PCR for BK virus revealed presence of <500 copies/mL of BK virus. Quantiferon gold, urine MTB PCR, and urine fungal culture were negative.

The presence of worsening hematuria raised suspicion for hemorrhagic cystitis due to adenovirus. Urine adenovirus PCR confirmed the diagnosis of AGP due to adenovirus.

DISCUSSION

Acute graft pyelonephritis, also known as pyelonephritis of the renal allograft, can be categorized as early-onset (<6 months after transplant) or late onset (>6 months after transplant). Early-onset AGP is associated with bacteremia, pyelonephritis, and high rate of relapse,^1-3 whereas late-onset AGP is associated with increased risk of graft loss.⁴

In a renal transplant patient, UTIs are usually caused by the same gram-negative bacteria that cause UTIs in patients without a transplant.⁵ Additionally, Pseudomonas aeruginosa and gram-positive bacteria such as those within the Enterococcus species should be considered. Candida albicans is the most common fungal cause and is associated with urinary obstruction.⁶

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