Kidney Matters - Issue 16 Spring 2022

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24Kidney ClinicClear water? UTIs after a kidney transplantThe most common infections to occur afterkidney transplantation, urinary tract infections(UTIs) can be a recurring problem but may besuccessfully treated with individualised diagnosisand treatment.UTIs can occur at any time after a kidney transplantand can affect any part of the urinary tract from thetransplanted and native kidneys to the bladder andurethra (the tube to the outside). UTIs are describedas early when they develop within six months of theoperation, and late if they occur more than six monthsafter transplantation. Infections are most commonlycaused by gut bacteria like E. coli, but may also be dueto viruses like BK, adenovirus and cytomegalovirus(CMV), or fungi such as candida.Between one in 10 (10%) and nearly all (98%) ofkidney transplant patients have been reported asbeing affected by UTIs. Reasons for this very widerange include varied use of preventive or prophylacticantibiotics and different definitions of UTI. This latterconfusion has been addressed by updated guidelines(Table 1), which aim to make diagnosis and treatmentless complex for patients and doctors.“I think it’s very important to understand that awhole spectrum of UTI exists and identifying it earlyforms the mainstay of management. The benefits oftreating all asymptomatic bacteriurias with antibioticsremain unclear in transplant patients and should bedecided on a case-by-case basis. Cystitis, which hasthe symptoms commonly associated with UTIs, isTable 1. Types of urinary tract infection (UTI) in kidney transplant recipientsType of UTIAsymptomaticbacteriuriaSimple cystitisAcute pyelonephritisor complicated UTIRecurrent UTIsDescription• Evidence of infection in the urine• But no urinary or general symptoms of infection• Burning, tingling or stinging pain when urinating (dysuria)• Pain in the lower abdomen (suprapubic pain)• No general symptoms of infection• No catheter into the bladder or tube directly into the kidney (nephrostomy) inplace• Fever, chills• Abnormal blood pressure (haemodynamic instability)• Increase in white cells in the blood (leukocytosis)• Pain over the transplanted kidney or at the side of the body• Bacteria in the urine• With/without symptoms of simple cystitis• Three or more UTIs over the previous 12 months or two in the last 6 monthsBased on: Goldman JD, Julian K. Clinical Transplantation 2019;33:e13507www.kidneycareuk.org
25primarily an infection of the bladder and the lowerurinary tract, and is usually resolved with a shortcourse of antibiotics. Pyelonephritis is an infection ofthe transplanted or the native kidneys, and can causesevere illness very quickly,” comments Ms Rhana Zakri.Rhana is a consultant transplant surgeon at Guy’sand St Thomas’ NHS Foundation Trust and runs aspecialist transplant UTI clinic.UTIs not only have a serious impact on quality of lifeand health of the individual patient, but may alsoaffect the lifespan of the transplanted kidney. Rhanaexplains:“While we would not necessarily worry about a singletreated UTI, we want to avoid recurrent episodes,as they can lead to pyelonephritis. If these episodesare repeated over several years, they may affectthe function of the kidney transplant and may alsoaffect its survival. At present it is unclear if recurrentUTIs per se cause rejection or whether rejectioncauses recurrent UTIs due to the higher doses ofimmunosuppression needed to treat rejection.”Why are UTIs common after a kidneytransplant?A combination of risk factors related to thetransplanted kidney (allograft factors) and factors todo with the individual patient (host factors) explainwhy UTIs are common in kidney transplant patients.Rhana says: “Most transplanted kidneys reflux urinefrom the bladder into the kidney when voiding. Byitself, this doesn’t cause a problem if the urine is notinfected and the bladder is emptied regularly, butcystitis can very quickly progress to pyelonephritisbecause of the reflux and potentially cause scarring tothe kidney.“Reflux makes it all the more important to not onlymaintain a good fluid intake but also perform regular(say, three hourly) double voids (see Table 2, below).This can be difficult in certain jobs; for example, lorrydrivers and taxi drivers are at risk of UTIs if they limittheir drinking because they cannot use the toilet whenthey need to,” she adds.Kidney transplant patients are treated with medicationthat suppresses the immune system, making it moredifficult to fight UTIs. These immunosuppressantsinclude mycophenolate, which can havegastrointestinal side effects, including diarrhoea orconstipation that can increase the risk of UTIs.Kidney transplant patients may have other host riskfactors, such as diabetes, that are associated with agreater likelihood of UTIs. Postmenopausal womanor women with a hysterectomy are similarly prone toUTIs because low oestrogen levels mean that ‘good’Lactobacilli bacteria, which usually lower the pH of thevagina, do not flourish, giving way to the possibility ofgut bacteria multiplying and potentially causing UTI.UTIs are more common in women than in men, bothin kidney transplant recipients and in the generalpopulation. The main reason is differences inanatomy: in women the vagina, entrance to the urethraand anus are sited close together, so that bacteria likeE. coli transfer more easily from the anus.“This is why a UTI in a man should be regarded as‘complicated’ because there is more likely to be anunderlying cause. For example, his prostate may havegrown larger and is preventing him from emptying hisbladder properly. Quite often, men may not realise thisis happening until they get a UTI,” says Rhana.How should UTIs be diagnosed?It can be difficult for doctors to diagnose a UTI in atransplant patient because immunosuppression maymask typical symptoms; for example, a transplantedkidney has lost its nerve supply so it may not feeltender or painful. Instead, kidney transplant patientsmay report feeling simply tired or feverish or havesmelly/cloudy urine, and can become ill very quickly.The first step to diagnosis is a dipstick and midstreamurine (MSU) to check for the growth of bacteria.This can be performed by your GP. The secondinvestigation is a flowrate with postvoid residualvolume (PVR) to see how well the patient voids andjudge how much urine is left behind in the bladder.This is more likely to be initiated by your kidney doctoror transplant urologist.A more specialist investigation is a DMSA scan, anuclear medicine scan that looks for scarring in thetransplanted kidney. “Management will be tailoredto the result of this scan. The patient may have anumber of these scans over the years to look forprogression of scarring. It is an indication of theseverity of the UTI, and that perhaps more aggressiveintervention is needed to prevent loss of graftfunction,” comments Rhana.Issue 16 | Spring 2022
Page 1 and 2: Spring 2022Issue 16Improvingorgan d
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