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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 13  |  Issue : 2  |  Page : 127-129

Multidrug-resistant coinfection and emphysematous pyelonephritis in a deceased donor allograft – Treatment dilemma


1 Department of General Surgery, Sri Ramachandra Medical College and RI, Chennai, Tamil Nadu, India
2 Department of Nephrology, Madras Medical Mission, Chennai, Tamil Nadu, India
3 Department of Microbiology, Madras Medical Mission, Chennai, Tamil Nadu, India
4 Department of Urology, Madras Medical Mission, Chennai, Tamil Nadu, India

Date of Submission18-Sep-2018
Date of Acceptance10-Jan-2019
Date of Web Publication28-Jun-2019

Correspondence Address:
Dr. Georgi Abraham
Madras Medical Mission, 4A, Dr. J.J. Nagar, Mogappair, Chennai - 600 037, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijot.ijot_57_18

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  Abstract 


Emphysematous pyelonephritis (EPN) is a severe, potentially fatal suppurative infection of the renal parenchyma and perirenal tissues. It is indicated by the production of gas within the kidney and perinephric tissues. Risk factors that contribute to the development include diabetes and female sex. Herein, we report EPN in a 59-year-old male who underwent renal transplant from a deceased donor earlier this year.

Keywords: Deceased donor kidney transplantation, diabetes mellitus, emphysematous pyelonephritis


How to cite this article:
Anupama SH, Abraham G, Mathew M, Rohit A, Kurien A. Multidrug-resistant coinfection and emphysematous pyelonephritis in a deceased donor allograft – Treatment dilemma. Indian J Transplant 2019;13:127-9

How to cite this URL:
Anupama SH, Abraham G, Mathew M, Rohit A, Kurien A. Multidrug-resistant coinfection and emphysematous pyelonephritis in a deceased donor allograft – Treatment dilemma. Indian J Transplant [serial online] 2019 [cited 2019 Jul 19];13:127-9. Available from: http://www.ijtonline.in/text.asp?2019/13/2/127/261843




  Introduction Top


Emphysematous pyelonephritis (EPN) refers to a necrotizing infection of the kidney commonly caused by gas-forming pathogens such as  Escherichia More Details coli and Klebsiella infrequently seen as a complication postrenal transplant. Risk factors include diabetes mellitus, urinary obstruction, and female sex. While the majority of reported cases have involved native kidneys, there have been 26 reports of emphysematous pyelonephritis involving renal allografts.[1] Anatomic abnormalities of the urinary tract in the renal transplant patient and immunosuppression may make diagnosis and management of emphysematous pyelonephritis more complicated. We report a case of emphysematous pyelonephritis involving a renal allograft. In emphysematous pyelonephritis, with the help of computed tomography (CT), air is visualized within the renal parenchyma, collecting system, or perinephric tissue. The average interval between renal transplant and the development of emphysematous pyelonephritis was 28 months (range: 2 weeks–7 years). CT scan is the imaging study of choice, although ultrasound examination may also show air in the kidney.


  Case Report Top


Here, we report a 59-year-old diabetic male patient who underwent a deceased donor transplantation elsewhere on April 19, 2018 and came for management of pyelonephritis of the allograft on June 23, 2018. Contrast CT scan showed perirenal leak and emphysematous pyelonephritis [Figure 1]. Urine culture grew Pseudomonas aeruginosa and Klebsiella pneumoniae resistant to all antibiotics except fosfomycin. On admission, all baseline investigations were done. White blood cell was found to be 11200/mm3, N: 97.1% L: 1.3% M: 1.4% B: 0.1% E: 0.1%, renal function test showed serum creatinine 1.20 mg/dl, blood urea 49 mg/dl, albumin 2.4 g/dl, and serum electrolytes were: sodium 132 mmol/l, potassium 4.6 mmol/l, bicarbonate 12 mmol/l, chloride 110 mmol/l, calcium 8.2 mg/dl, and phosphorus 2 mg/dl. The patient was on triple immunosuppressant therapy with prednisolone 10 mg/day once a day, tacrolimus 1.5 mg/day, and mycophenolate mofetil (MMF) 1 g/day, both twice daily. The patient gave a history of percutaneous nephrostomy (PCN) on June 03, 2018 and removal of double-J stent on May 31, 2018, implanted at the time of transplantation from an outside hospital. As there was a persistent hydronephrosis of the allograft, a repeat PCN was done here. The combined urine output from PCN and urethra of the patient varied between 1100 and 2100 cc/day. The patient was initiated on colistin 9 million units stat followed by 4.5 million units twice daily and imipenem 1 g stat followed by 1 g twice daily, parenterally. The serum trough tacrolimus level as on June 25, 2018, was 12.5 ng/ml. Hence, the tacrolimus dosage was decreased to 1 mg, prednisolone 5 mg, and MMF to 500 mg, twice daily. Over the next few days, there was an increase in serum creatinine to 2.58 mg/dl. Hence, colistin and imipenem were discontinued and the patient was started on fosfomycin 3 g IV BD. The patient was continuously monitored by the infectious diseases, nephrology, and urology team. The patient was discharged on request for outpatient care and was lost to follow-up.
Figure 1: Emphysematous pyelonephritis in the allograft

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  Discussion Top


EPN is a rare gas-forming, necrotizing infection of the renal parenchyma. Renal allografts are more susceptible to infections due to the absence of Gerota's fascia.[2] It is lethal unless treated appropriately. The literature describes the outcome of 26 cases.

In our patient, treatment was initiated elsewhere and the organisms isolated from the urine were Pseudomonas aeruginosa and K. pneumonia which were multidrug resistant, sensitive to fosfomycin. Cultures taken earlier in the course of the disease showed organisms sensitive to multiple antimicrobial agents which lead to cure then. The urologist was inclined to connect the pelvis of the transplant kidney to the native ureter of the patient to prevent necrosis of the unhealthy ureteroneocystostomy. Although the patient was advised graft nephrectomy as a life-saving procedure, he refused and was lost to follow-up.

As the diagnosis of EPN depends on imaging, CT is the gold standard for diagnosis and follow-up, unlike magnetic resonance imaging.[3] There are different classifications of EPN. Al-Geizawi et al. classified EPN in an allograft kidney as shown in [Table 1].[2]
Table 1: Classification of emphysematous pyelonephritis in allograft kidneys according to Al-Geizawi et al.[2]

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According to the classification, our patient had Stage II, which is gas in <50% of renal parenchyma; however, the response to antibiotic therapy was suboptimal due to multidrug-resistant organisms, with progressive graft dysfunction. Management strategy in EPN involves reduction/discontinuation of immunosuppressant and antimicrobials and allograft removal for resistant infections. Management of EPN in allograft kidney as per Al-Geizawi et al. is shown in [Table 2].[2]
Table 2: Stage-wise management of emphysematous pyelonephritis in allograft kidneys[2]

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Aggressive medical management of EPN in allograft, including pelvicalyceal dilatation, was first described in 1986 by Hudson et al.[4] This includes fluid and electrolyte correction, targeted antibiotic therapy, strict glycemic control, and reduction in immunosuppression. In Stage 2 disease, early, regular, and frequent follow-up imaging (ultrasound or noncontrast CT scans) is required to gauge the requirement for more drains or repositioning/changing of drains. Nephrectomy is indicated in Stage 3 disease and in patients who progress to Stage 3 during the course of management after unsuccessful attempts to salvage the transplanted kidney.[5] As the management is a challenge, a multidisciplinary team consisting of clinical microbiologists, urologists, transplant surgeons, and nephrologists should be involved in day-to-day care. Good glycemic control, early diagnosis, and prompt management of urinary tract infections may prevent the development of EPN.


  Conclusion Top


This case report presents a male patient with multidrug-resistant coinfection and emphysematous pyelonephritis in a deceased donor allograft kidney, treated with triple immunosuppression therapy and appropriate antibiotics. In view of progressive disease, the patient was advised graft nephrectomy as a life-saving procedure, which he declined. The patient was discharged on request for outpatient care and was lost to follow-up.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patients have given their consent for their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Narcisse D, Agarwal M, Hancock M, Wells D, Sands C. A rare case of emphysematous pyelonephritis in a renal transplant patient. Ther Adv Infect Dis 2016;3:141-4.  Back to cited text no. 1
    
2.
Al-Geizawi SM, Farney AC, Rogers J, Assimos D, Requarth JA, Doares W, et al. Renal allograft failure due to emphysematous pyelonephritis: Successful non-operative management and proposed new classification scheme based on literature review. Transpl Infect Dis 2010;12:543-50.  Back to cited text no. 2
    
3.
Craig WD, Wagner BJ, Travis MD. Pyelonephritis: Radiologic-pathologic review. Radiographics 2008;28:255-77.  Back to cited text no. 3
    
4.
Hudson MA, Weyman PJ, van der Vliet AH, Catalona WJ. Emphysematous pyelonephritis: Successful management by percutaneous drainage. J Urol 1986;136:884-6.  Back to cited text no. 4
    
5.
Laway BA, Bhat MA, Bashir MI, Ganie MA, Mir SA, Daga RA, et al. Conservative management of emphysematous pyelonephritis. Indian J Endocrinol Metab 2012;16:303-5.  Back to cited text no. 5
    


    Figures

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    Tables

  [Table 1], [Table 2]



 

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