Persistent Shortness of Breath in a Kidney Transplant Recipient


American Journal of Transplantation Images in Transplantation – Continuing Medical Education (CME)

Each month, the American Journal of Transplantation will feature Images in Transplantation, a journal-based CME activity, chosen to educate participants on current developments in the science and imaging of transplantation. Participants can earn 1 AMA PRA Category 1 Credit™ per article at their own pace.

This month's feature article is titled: “Persistent Shortness of Breath in a Kidney Transplant Recipient.”

Accreditation and Designation Statement

This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of Blackwell Futura Media Services, the American Society of Transplant Surgeons and the American Society of Transplantation. Blackwell Futura Media Services is accredited by the ACCME to provide continuing medical education for physicians.

Blackwell Futura Media Services designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Statement of Need

Shortness of breath after kidney transplantation is a nonspecific complaint and may be related to both common and uncommon causes, including rare infections in the immunosuppressed patient. It is important to identify the precipitating cause of dyspnea as if left untreated, it can be fatal.

Purpose of Activity

This activity is designed to improve the competency in diagnosis and management of pulmonary infections in kidney transplant recipients.

Identification of Practice Gap

Kidney transplant recipients presenting with shortness of breath should be evaluated systematically as they can have a wide range of pathology with atypical clinical presentation. The differential diagnosis is broad but should include rare infections after common etiologies have been ruled out.

Learning Objectives

Upon completion of this educational activity, participants will be able to:

  • Consider atypical infections when encountered with an immunosuppressed patient with persistent shortness of breath.
  • Describe risk factors for this infection and discuss appropriate diagnostic testing.
  • Discuss appropriate treatment options and usual outcomes of this infection.

Target Audience

This activity has been designed to meet the educational needs of physicians and surgeons in the field of transplantation.


No commercial support has been accepted related to the development or publication of this activity. Blackwell Futura Media Services has reviewed all disclosures and resolved or managed all identified conflicts of interest, as applicable.


Allan D. Kirk, MD, PhD, FACS, has no relevant financial relationships to disclose.


Sandy Feng, MD, PhD, has no relevant financial relationships to disclose.

Douglas W. Hanto, MD, PhD, has no relevant financial relationships to disclose.


Faris Ahmed, MD, J. Harold Helderman, MD, Anthony Langone, MD, and Heidi Schaefer, MD, have no relevant financial relationships to disclose.

ASTS Staff

Mina Behari, Director of Education, has no relevant financial relationships to disclose.

This manuscript underwent peer review in line with the standards of editorial integrity and publication ethics maintained by the American Journal of Transplantation. The peer reviewers have no relevant financial relationships to disclose. The peer review process for the American Journal of Transplantation is blinded. As such, the identities of the reviewers are not disclosed in line with the standard accepted practices of medical journal peer review.

Instructions on Receiving CME Credit

This activity is designed to be completed within an hour. Physicians should claim only those credits that reflect the time actually spent in the activity. This activity will be available for CME credit for twelve months following its publication date. At that time, it will be reviewed and potentially updated and extended for an additional twelve months.

Follow these steps to participate, answer the questions and claim your CME credit:

  • Log on to
  • Read the learning objectives, target audience, and activity disclosures.
  • Read the article in print or online format.
  • Reflect on the article.
  • Access the CME Exam, and choose the best answer to each question.
  • Complete the required evaluation and print your CME certificate.

A 43-year-old man with a history of end-stage renal disease secondary long-standing type II diabetes and hypertension underwent successful deceased donor kidney transplant with immediate allograft function and nadir creatinine 1.0 mg/dL. His induction immunosuppression included alemtuzumab 30 mg and solumedrol. His maintenance immunosuppression was tacrolimus, mycophenolate mofetil and prednisone. His postoperative course was uneventful apart from uncontrolled blood glucose. Tacrolimus levels were maintained between 8–10 ng/mL without acute rejection episodes. Two months after transplant, he presented to the clinic with dyspnea on exertion and dry cough. He denied tobacco use and his tuberculin skin test was negative previously. He denied recent travel or sick contacts. He was born in Mexico but had lived in Tennessee for 18 years employed as a construction worker. His chest X-ray was unremarkable and cardiac work-up including electrocardiogram and echocardiogram was negative for ischemia and depressed ejection fraction. He was prescribed an Albuterol inhaler with some improvement in symptoms, but 2 weeks later presented to the emergency room with worsening shortness of breath and 1-day history of fever and hemoptysis. At the time of evaluation, his temperature was 37.6 C° with oxygen saturation of 97% on room air. His white blood cell count was 11.6 × 109/L, creatinine 1.19 mg/dL, glucose 144 mg/dL and tacrolimus level 6.3 ng/mL. CT scan of the chest showed a subcarinal mass with possible erosion into the left main stem bronchus resulting in airway obstruction and postobstructive pneumonia (Figure 1). A diagnostic procedure was performed.

  • F. Ahmed, J. H. Helderman, A. Langone and H. Schaefer*

  • Department of Internal Medicine, Division of Nephrology, Vanderbilt University, Nashville, TN

  • *Corresponding author: Heidi M. Schaefer,

Figure 1.

Chest CT scan, arrow showing endobronchial lesion in left main stem bronchus.

Figure 2.

H&E stain of endobronchial tissue biopsy.


  1. Based on Figure 2, the most likely etiology of this patient's symptoms and CT findings is:
    1. Pulmonary tuberculosis
    2. Mucormycosis
    3. Histoplasmosis
    4. Sarcoidosis
    5. Legionella
  2. Which of the following is a major risk factor for this disorder?
    1. Anti-TNF-alpha therapies
    2. Hepatitis C infection
    3. Living in the Ohio River Valley
    4. Uncontrolled diabetes mellitus
    5. Smoking history
  3. The diagnostic test for this disorder is:
    1. Tissue biopsy or culture showing causative organisms
    2. Positive PPD test
    3. Positive urine antigen test
    4. Elevated serum angiotensin converting enzyme (ACE) level
    5. Blood cultures for fungus
  4. The mainstay of treatment for this disorder is:
    1. Itraconazole
    2. Surgical resection
    3. Amphotericin B
    4. Prednisone
    5. Azithromycin
  5. Which of the following is TRUE regarding the outcome of this disorder?
    1. The mortality rate is 50–80%.
    2. This is a self-limiting condition with symptomatic treatment.
    3. Medical treatment has a 95% cure rate.
    4. Renal allograft loss is almost guaranteed in affected patients.
    5. Most patients will require lifelong antifungal therapy.

To complete this activity and earn credit, please go to