Fever and Suprapubic Tenderness Ten Days After Kidney Transplantation


M. H. Levine, matthew.h.levine@uphs.upenn.edu

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 entitled: “Fever and Suprapubic Tenderness Ten Days After Kidney Transplantation.”

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

All transplant recipients are at risk of developing infections. Developing a concise differential diagnosis for serious infectious postoperative complications and directing the subsequent narrowing of this differential to a single diagnosis is crucial for effective management of complications and must be done in a timely fashion. This activity will address the knowledge gap in identifying and managing infectious complications in the early period after renal transplantation, with an emphasis on diagnosing and treating serious infection while preserving the functioning transplant and thereby improving graft and patient outcomes.

Educational Objectives

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

  • • Diagnose a serious complication of kidney transplantation
  • • Formulate a set of risk factors for this pathophysiologic process
  • • Develop an effective treatment regimen for this transplant complication

Target Audience

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

Activity Disclosures

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. The following authors, editors, and staff reported no relevant financial relationships with respect to this activity.


Allan D. Kirk, MD, PhD, FACS


Sandy Feng, MD, PhD

Douglas W. Hanto, MD, PhD


Matthew H. Levine, MD, PhD

Paige M. Porrett, MD, PhD

ASTS Staff

Mina Behari, Director of Education

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 http://www.amjtrans.com/cme
  • • Read the target audience, educational objectives, 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.

The patient is a 67-year-old diabetic female who received a retroperitoneal kidney transplant into the right iliac fossa. Because of a prior history of voiding dysfunction, she was discharged with an indwelling Foley catheter. Ten days after transplantation, she presented to the emergency room with a fever of 101.5 degrees, a new onset of exquisite suprapubic tenderness and dysuria, a white blood cell count of 26.5 × 103 cells/uL and a serum creatinine of 0.9 mg/dL. A CT scan of the abdomen and pelvis with oral and intravenous contrast was performed (Figure 1). She was started on piperacillin and tazobactam but she clinically did not improve over 48 hours. Vancomycin was added. Urine cultures grew >100 000 colony forming units of E. coli. She was then taken to the operating room for a surgical procedure (Figure 2). Operative cultures grew E. coli, streptococcus species, and Lactobaccilus gasseri. Postoperatively, she underwent a percutaneous nephrostogram and placement of a percutaneous nephro-ureteral catheter for urinary diversion (Figure 3). The Foley catheter was maintained. After 3 months of urinary diversion, the catheters were sequentially removed and she has fully recovered with excellent function of the transplanted kidney. She is voiding normally.

Figure 1.
Figure 2.
Figure 3.


  • 1Based on the CT scan findings, what is the most likely diagnosis?
    • a.   Transplant pyelonephritis
    • b.   Colonic perforation
    • c.   Fournier's gangrene
    • d.   Infected pelvic hematoma
    • e.   Emphysematous cystitis
  • 2Other than pharmacologic immunosuppression and diabetes mellitus, what factor is MOST likely to contribute to the risk of this complication?
    • a.   Patient age greater than 65
    • b.   Colonic diverticulosis
    • c.   Indwelling Foley catheter
    • d.   Recipient obesity
    • e.   Retroperitoneal placement of transplanted kidney
  • 3Why is complete urinary diversion necessary in this patient, as evidenced in Figure 3?
    • a.   Bladder perforation with urinary extravasation
    • b.   Bladder outlet obstruction
    • c.   Stricture of the transplant ureter
    • d.   Leak of the transplant ureter
    • e.   Colonic perforation eroding into renal collecting system
  • 4In addition to urinary diversion, what operative procedure is appropriate treatment of this patient?
    • a.   Hematoma evacuation and retroperitoneal drainage
    • b.   Diverting colostomy and abscess drainage
    • c.   Bladder debridement
    • d.   Revision of uretero-neocystotomy to uretero-ureterostomy
    • e.   Seroma marsupialization
  • 5What is the most common organism responsible for a gas producing soft tissue infection in an immunosuppressed patient?
    • a.   Group A Streptococcus
    • b.   E. coli
    • c.   Clostridium species
    • d.   Staphylococcus species
    • e.   Enterococcus

To complete this activity and earn credit, please go to http://www.amjtrans.com/cme