1Department of Nephrology 2Department of Urology Christian Medical College Vellore, Tamil Nadu India Email: george{at}cmcvellore.ac.in
Case
A 39-year-old female, who underwent renal transplantation 2 years earlier, was referred to our unit with a 2 week history of high-grade fever and graft dysfunction. She was on an immunosuppressive regime containing cyclosporin, azathioprine and prednisolone. Six months post-transplantation she developed hyperglycaemia and was treated with insulin. Nine months later she developed disseminated tuberculosis and received antituberculous therapy. At the time of referral, apart from immunosuppressives, she was on isoniazid 200 mg and ethambutol 400 mg, daily. Her serum creatinine ranged between 1.5 and 1.8 mg/dl in the past year.
On examination she was febrile, normotensive and complained about vague abdominal discomfort. The abdomen was distended with no tenderness guarding or rigidity, but bowel sounds were absent. She was anuric with anasarca and had fine basal crackles. She was disoriented but without focal neurological deficits. Investigations revealed a serum creatinine of 3.9 mg/dl and arterial blood gas analysis showed metabolic acidosis (pH 7.195, pCO2 24.1 mmHg, pO2 87.8 mmHg, HCO3 14 mmol/l, ABE -9.4 mmol/l, sO2 96.4%). She had a platelet count of 12 000/mm3, white blood cell count of 36 900/dl with 90% polymorphs and a blood sugar of 343 mg/dl. An X-ray of the abdomen in the erect position (Figure 1) was taken followed by an ultrasonogram. A few hours later, she developed pulmonary oedema and hypotension with a blood pressure of 90/60 mmHg. While on ionotropic support she received haemodialysis.
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Answers to the quiz on the preceding page
The X-ray of the abdomen showed an abnormal gas shadow in the right iliac fossa corresponding to the graft kidney area. A helical computerized tomography (CT) scan of the abdomen showed features of emphysematous pyelonephritis (EPN) of the graft kidney (Figure 2) with perirenal extension. Relatives of the patient refused to consent for a graft nephrectomy. A CT-guided percutaneous nephrostomy was made and 200 ml pus admixed with air was drained. The culture of pus and blood grew Escherichia coli sensitive only to meropenem/imipenem. After 5 days with four sessions of haemodialysis and appropriate antibiotics, she became normotensive and her general condition improved. The serum creatinine stabilized at 2.3 mg% and platelet count became normal. After 12 days of drainage a repeat CT scan showed complete resolution of the emphysematous cavity (Figure 3). She was discharged and, subsequently, the nephrostomy tube was removed. Following this she recovered and graft function remained stable.
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In a review of EPN of the native kidney [3], the renal involvement according to the severity is graded as: class 1, gas in the collecting system only; class 2, gas in the renal parenchyma without extension to extrarenal space; class 3A, extension of gas or abscess to perinephric space; class 3B, extension of gas or abscess to pararenal space; and class 4, bilateral EPN or solitary kidney with EPN. Class 3 or 4 patients with two or more risk factors, such as thrombocytopenia, acute renal functional impairment, disturbance of consciousness or shock, have a significantly higher failure rate with percutaneous drainage and antibiotics when compared with nephrectomy.
This renal allograft recipient is one of the rare patients with an EPN of the graft complicated by multiorgan failure, who could be treated successfully with percutaneous drainage and antibiotics.
Conflict of interest statement. None declared.
References