49 Emphysematous Pyelonephritis in Renal Allograft Successfully Treated with Medical Management

Abstract

EMPHYSEMATOUS PYELONEPHRITIS IN RENAL ALLOGRAFT SUCCESSFULLY TREATED WITH MEDICAL MANAGEMENT Guillermo Carnero, Susmitha Dhanyamraju, Junu Bhattarai, Rajesh Govindasamy, Michael Schultz. Geisinger Medical Center, Danville, PA Emphysematous pyelonephritis (EPN) is rare and life-threatening necrotizing bacterial infection of the kidney caused by gas-forming organism, mostly in diabetic patients and often requires nephrectomy. We report the case of EPN in renal allograft successfully treated with medical therapy. A 51 year old woman with history of cadaveric kidney transplant 1.5 years back presents to the emergency department with fever, hypotension and vomiting. On admission she appeared acutely ill and dry on physical examination; she had no graft tenderness. She was noted to have diabetic keto-acidosis. Blood urea nitrogen and creatinine level of 67 mg/dl and 4.3 mg/dL respectively from baseline of 20 mg/dl and 1.2 mg/dl. Her white cell count was elevated with bandemia of 16% and her serum tacrolimus level was 5.2 ng/mL. Urine analysis showed numerous WBC and bacteria. Patient was treated with intravenous hydration, insulin infusion and broad spectrum antibiotics. Prograf and Cellcept were held and patient was started on stress dose steroid. Kidney transplant doppler ultrasound showed echogenic foci which likely represented a gas forming infection. CT scan without contrast showed an enlarged and heterogeneous attenuation in right lower quadrant transplant with several pockets of parenchymal gas most consistent with emphysematous pyelonephritis. Two nonobstructive renal calculi in the transplanted kidney were found. Blood and urine cultures grew pan sensitive Escherichia coli responding to intravenous Ceftriaxone. Her general condition improved and sepsis and ketoacidosis resolved. Her allograft function improved and her BUN and creatinine were 27 mg/dl and 1.4 mg/dL at discharge. This is a rare presentation of EPN in a renal allograft associated with calculi. No real consensus exists on the optimal treatment of EPN in kidney transplant recipients and some debate on need for nephrectomy. In conclusion, this case demonstrates successful non-operative therapy of EPN with aggressive medical management in a kidney transplant recipient who presents with urosepsis, shock and renal failure.