Fever, Abdominal Pain and Renal Failure in a Kidney Transplant Recipient


Corresponding author: Didier A. Mandelbrot, dmandelb@bidmc.harvard.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 titled “Fever, Abdominal Pain and Renal Failure 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

Due to immunosuppression, all transplant recipients are at high risk of developing infections. Clinical presentation of transplant recipients may be atypical leading to difficulties in diagnosis and management. The evaluation and management of a kidney transplant recipient with fever, abdominal pain and acute renal failure continues to present a challenge.

Purpose of Activity

This activity will improve the competence of the transplant multidisciplinary team in evaluating and managing transplant recipients presenting with a constellation of fever, abdominal pain and renal failure.

Identification of Practice Gap

Clinical presentation of transplant recipients can be atypical leading to difficulties and delays in diagnosis and management. This activity is designed to improve the skill of the transplant multidisciplinary team in evaluating and managing transplant recipients presenting with a constellation of fever, abdominal pain and renal failure.

Learning Objectives

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

  • Recognize the radiological appearance of an inflamed renal allograft
  • Describe the histopathology of transplant pyelonephritis
  • Determine the most appropriate intervention 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.


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


Ajay Kher, MBBS, Kristin E. Raven, MD, Yael B. Kushner, MDCM, and Didier A. Mandelbrot, MD

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 https://www.wileyhealthlearning.com/ajt.
  • 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 39-year-old female with end-stage renal disease (ESRD) from familial focal segmental glomerulosclerosis (FSGS) had a history of two previous allograft failures due to acute humoral rejection. She underwent her third deceased donor renal transplant 1 year ago and subsequently has had a baseline creatinine of 1.4–1.6 mg/dL. Posttransplant, she had been treated for two episodes of multidrug resistant Escherichia coli urinary tract infection, and hence was on fosfomycin suppression therapy. Maintenance immunosuppression was tacrolimus, sirolimus and prednisone. A few days prior to admission at our institution, she presented to an outside hospital with 3 days of nausea, vomiting, diarrhea and right lower quadrant (RLQ) abdominal pain. She was febrile at 103F, hypotensive and tender in the RLQ. After receiving 6L NS, she was transferred to our care. Her creatinine at presentation was 3.2 mg/dL and increased to 5.1 mg/dL the next day. White blood cell count was 17.8, urinalysis had 8 WBC/HPF and few bacteria, and urine culture was negative. Renal ultrasounds, including Doppler, were normal except for a small amount of fluid surrounding the upper pole of the renal transplant. Her computed tomography (CT) scan is shown in Figure 1. She was taken to the operating room and underwent an open appendectomy (Figure 2) and a kidney biopsy (Figure 3).

Figure 1.

CT scan of abdomen and pelvis.

Figure 2.

Appendix (hematoxylin and eosin stain, 40X). Inset 100X.

Figure 3.

Kidney biopsy (hematoxylin and eosin stain, 100X).


  1. The CT scan (Figure 1) with oral contrast reveals:
    1. Dilated appendix with fat stranding and enlarged, edematous renal allograft
    2. Normal appendix and normal renal allograft
    3. Dilated appendix with fat stranding and normal renal allograft
    4. Perforated appendicitis with normal renal allograft
    5. Normal appendix with enlarged, edematous renal allograft
  2. The appendix pathology (Figure 2) reveals:
    1. Normal appendix
    2. Acute appendicitis
    3. Perforated appendicitis
    4. Granulomatous appendicitis
    5. Appendiceal adenocarcinoma
  3. The kidney biopsy (Figure 3) reveals:
    1. Acute tubular necrosis
    2. Transplant pyelonephritis
    3. Acute interstitial nephritis
    4. BK nephropathy
    5. Acute rejection
  4. The cause of this patient's symptoms and AKI is:
    1. Acute rejection
    2. Acute appendicitis with acute tubular necrosis
    3. Transplant pyelonephritis
    4. BK nephropathy
    5. Acute interstitial nephritis
  5. The most appropriate intervention in addition to volume resuscitation is:
    1. Antibiotics
    2. Steroids
    3. Treatment of tuberculosis
    4. Reduction of immunosuppression
    5. Appendectomy

To complete this activity and earn credit, please go to https://www.wileyhealthlearning.com/ajt