Urinary infection in kidney transplantation

Strong inflammatory cytokine response in male and strong anti-inflammatory response in female kidney transplant recipients with urinary tract infection

Urinary tract infection (UTI) is the most common post-transplant infection in renal transplant recipients. The relationship of plasma and urine cytokines with UTI after kidney transplantation has not yet been delineated and literature reports on cytokine and UTI are rare. In a retrospective study, we compared post-transplant plasma and urine cytokine levels of 132 outpatient renal transplant recipients with or without UTI. Soluble interleukin-1 receptor antagonist (sIL-1RA), IL-2, sIL-2R, IL-3, IL-4, IL-6, sIL-6R, IL-8, IL-10, transforming growth factor-beta2 (TGF-beta2), interferon-gamma (IFN-gamma), and tumor necrosis factor-alpha (TNF-alpha) levels were determined using commercially available enzyme-linked immunosorbent assay (ELISA) kits. We found gender-related urine cytokine patterns. Anti-inflammatory sIL-1RA was significantly higher in females than in males and this gender-related difference was more pronounced in bacteriuric (P < 0.0001) than in nonbacteriuric (P = 0.001) patients. Urine proinflammatory cytokines IL-6 (P = 0.001) and IL-8 (P = 0.007) were significantly higher in male patients with bacteriuria than in males without bacteriuria and sIL-2R (P = 0.001) and sIL-6R (P = 0.03) were significantly higher in males with leukocyturia than in males without leukocyturia. Bacteriuria in males was associated with higher doses of immunosuppressive drugs (P = 0.02). Male renal transplant recipients with UTI have a strong inflammatory cytokine response with activation of IL-6, IL-8, sIL-2R and sIL-6R producing cells, whereas female patients with UTI block the inflammatory response to UTI by production of sIL-1RA.

Catheter-associated urinary infection in kidney post-transplant patients

CONTEXT

There is still controversy as to the use and dosage of antimicrobial prophylaxis of the urinary infection associated with urethral catheterization in the post renal transplant period.

OBJECTIVE

To determine whether patients develop urinary infection during short-term urethral catheterization after renal transplant without routine antimicrobial prophylaxis.

DESIGN

Prospective study.

SETTING

Kidney Transplantation Unit.

SAMPLE

20 patients submitted to non-complicated kidney transplant, with a normal urinary tract and no risk factors present regarding urinary infection. Aged 15 to 65 years.

MAIN MEASUREMENTS

Before the transplant, material from the urethral meatus and urine were collected for culture. After the transplant, in the period during which the patient was with short-term urethral catheterization (4 to 5 days), material from the urethral meatus and urine from the bladder and the collecting bag were taken daily from all recipients for culture.

RESULTS

There was a predominance of coagulase-negative Staphylococcus and S. viridans in the normal urethral meatus flora and in the first two days of urethral catheterization. After the second day, there was a predominance of E. coli and E. faecalis. Urinary infection did not occur during the period of urethral catheterization. In the follow up only one female patient (7%) had asymptomatic bacteriuria caused by E.coli after the withdrawal of the urethral catheter.

CONCLUSIONS

Infection urinary does not occur during the period of urethral catheterization in kidney post-transplant patients. Thus, antimicrobial prophylaxis is not recommended for these patients to prevent urinary infection.

Prevalence of urinary tract infection during outpatient follow-up after renal transplantation

Seven hundred and twenty-seven renal transplant patients are reviewed with respect to the occurrence of urinary tract infection (UTI) after renal transplantation. UTI was defined as the detection of both bacteriuria (10(5) CFU/ml) and pyuria (10 leukocytes/hpf). UTI developed in 11 of the inpatients (20.8%) and in 30 (4.2%) of the outpatients during a one-year period. Among outpatients, 12 had symptomatic infections, comprising seven with acute pyelonephritis and five with acute cystitis. Asymptomatic UTI was detected in 18 patients. In addition, asymptomatic bacteriuria without pyuria was observed in ten (1.4%) patients. UTI was more common in patients with diabetes, and underlying urinary tract complications were present in some patients. Administration of trimethoprim-sulfamethoxazole for about 4 months is suggested to reduce the frequency of UTI in the early period after renal transplantation.

Prospective study of renal transplant infections in 50 consecutive patients

A prospective study of the frequency, timing, etiology and risk factors of infections in renal transplant recipients during the first year after transplantation was conducted in 50 consecutive patients. Neither prophylaxis with trimethoprim-sulfamethoxazole nor antiviral prophylaxis was administered. Two hundred twenty-eight episodes of infection were registered (4.5 per patient), 19 of which were severe. Forty-seven percent of all infectious episodes occurred during the first two months after transplantation. The more frequent infections were bacterial (64%), viral (22%) and fungal (11%). Escherichia coli was the most common agent isolated (n = 36), followed by cytomegalovirus (n = 32). Urinary tract infections were most common (n = 144), especially asymptomatic bacteriuria (n = 106). Surgical reintervention and the use of anti-lymphocytic globulins were associated with a higher frequency of severe infections (p < 0.05), and invasive candidiasis was associated with allograft loss (p < 0.03). Annual survival rates of patients and allografts were 100% and 94%, respectively. The frequency of mild infections was higher than that observed in other studies using bacterial or viral prophylaxis. Nevertheless, the number of severe infections and the survival rates of patients and allografts were similar to those reported in previous studies.

Bacterial urinary tract infection in cyclosporine-A immunosuppressed renal transplant recipients

Urinary tract infection and rejection in 48 renal transplant patients immunosuppressed with cyclosporine-A monotherapy were analysed. Urinary tract infection was diagnosed in 52% of the cases with Escherichia coli dominating. Urinary tract infection took a mild and relatively uncomplicated course as only one case of graft pyelonephritis caused graft nephrectomy and no influence on graft survival was observed (p greater than 0.05) in the infected cases in contrast to rejection episodes which caused a significantly reduced graft survival (p less than 0.01).

Genitourinary complications in renal transplantation

The surgical aspects of renal transplantation have now been studied thoroughly. Yet, technical complications are still common. This review may seem too complex, but proper attention to many small details means the difference between success and failure, or at least between large and small morbidity. Reduction of genitourinary complications is due to many innovations. The external ureteroneocystostomy is a primary method of urinary reconstruction which is simpler and produces fewer complications than the alternative procedures. Further, the complications that do occur are more easily and promptly treated. The end-to-side ureteroureterostomy, as currently performed, provides a ready secondary method of reconstruction if the primary method fails. The early exploration and operative correction of genitourinary complications substantially reduces long-term morbidity and mortality.

Altered patterns of posttransplant urinary tract infections associated with perioperative antibiotics and curtailed catheterization

Postoperative urinary tract infections (UTIs) in renal transplant patients were studied before and after introduction of a protocol requiring single-dose perioperative antibiotics and earlier catheter removal. The overall incidence of UTIs was reduced from 55.4% to 26%. The most dramatic reduction was in nondiabetic males, from 56% to 8.2%. There was a small but statistically insignificant reduction in infection rates in females. There was no change in the rate of infection in diabetics. The incidences of noncoliform and mixed infections, in the group as a whole, were dramatically reduced from 42.9% to 12%, but Escherichia coli infections were totally unaffected. This protocol exposed the special susceptibility of women and diabetics to posttransplant UTIs and the different pathogenesis of E coli versus noncoliform infections. These features need more study.

Nosocomial urinary tract infections: secular trends, treatment and economics in a university hospital

During a 71-month interval 3,024 nosocomial urinary tract infections were identified by prospective surveillance at our hospital. The annual attack rate varied between 2.0 and 3.1 per 100 admissions. Gram-negative bacilli caused 74 per cent of all urinary infections and recurrent infections in the hospital accounted for only 1 per cent. The most frequent pathogens were Escherichia coli (24 per cent), Pseudomonas aeruginosa (8 per cent), Streptococcus faecalis (7 per cent), Klebsiella pneumoniae (6 per cent) and Proteus mirabilis (6 per cent). Candida species caused 10 per cent of the infections and may represent a hospital-acquired pathogen of increasing importance. The burn unit had a significantly higher proportion of Enterobacter infections (21 per cent) than any other service (p less than 0.05). The plastic surgery service had more Serratia infections (24 per cent), whereas obstetrics and gynecology had more Escherichia coli infections (47 per cent) relative to other hospital services. More than 99 per cent of the patients with nosocomial urinary tract infections received antimicrobial drugs; in 63 per cent the chart documented that drug therapy was prescribed specifically for treatment of the urinary infections. Hospital-acquired urinary infections added approximately 1 million dollars to hospital expenses during the study interval. Estimates were made of the economic benefits of successful control programs.

Urinary tract infection in pediatric renal transplantation

Urinary tract infection is a frequent complication following renal transplantation and represents a potential focus for systemic infection in the immunosuppressed transplant recipient. The incidence, etiologic factors, temporal pattern, bacteriology, and prognostic significance of urinary tract infection were determined by analysis of 85 renal allografts in 69 patients. Significant bacteriuria occurred after 49 of 85 transplants (58 per cent). The incidence of infection was not related to success or source of the allograft, but was related to patient gender. Urinary tract infections developed in 68 per cent of females, while only 43 per cent of males became infected (p less than 0.05). Escherichia coli caused most first infections (30 per cent), while Pseudomonas aeruginosa and E. coli were equally responsible for recurrent infections (25 per cent each). Children with previous reconstructive urologic surgery had similar allograft success (63 per cent) and infection rates (53 per cent) as our other children (61 per cent and 58 per cent, respectively). No apparent correlation was noted between episodes of infection and graft rejection. Thorough preoperative assessment and preparation and prompt, specific treatment minimize the adverse influences of urinary tract infection.

Association between Streptococcus faecalis urinary infections and graft rejection in kidney transplantation

In the first month after transplantation 50% of 193 consecutive renal transplant recipients had bacteriuria. The most common organisms isolated were Streptococcus faecalis (34), Escherichia coli (28), Pseudomonas spp. (11), and staphylococcus (9). There was a significant correlation between infection with Str. faecalis and graft failure at one, three, and twelve months. This observation suggests that urinary infection with Str. faecalis may be associated with graft failure which is probably the result of immunological factors.

Anaerobic bacteriuria in renal transplantation

Renal allograft recipients were studied prospectively utilizing improved culture techniques to investigate anaerobic bacteriuria. The study population was compared with a population of patients with chronic renal insufficiency and end stage renal disease. The over-all incidence of anaerobic urinary tract infection was 7.5 per cent while the over-all incidence of aerobic urinary tract infection was 23.5 per cent. Patients with cadaver renal transplants during the early postoperative period had the highest incidnece of both anaerobic (42.9 per cent) and aerobic (71.4 per cent) urinary tract infection of all groups. The potential association between significant anaerobic bacteriuria during the first postoperative month and poor prognosis for cadaver renal allografts merits further investigation.

Urologic complications in renal transplantation

The current overall reported incidence of major urologic complications following renal transplantation is 5 per cent. The presence of such a complication increases the likelihood of patient mortality by a factor of three. Standard utilization of postoperative radionuclide scanning is very useful in early diagnosis. Vesical fistulas generally result from improper bladder closure. The incidence of bladder complications increases with secondary and tertiary grafts. Ureteral complications result when the blood supply of the ureter is impaired. These include fistula formation, necrosis, and obstruction. Immediate surgical correction is indicated in almost all serious urologic complications following transplantation; otherwise there is marked increase in morbidity and mortality. Complications appearing early in the postoperative period carry a poor prognosis for both graft and recipient survival. The presence of urinary tract infection early in the postoperative period also correlates negatively with graft survival. The presence of multiple renal arteries in the donor has been associated with an increased rate of urologic complications. Ureteral fistulas can be avoided by meticulous dissection of the donor at the time or organ harvesting. Great care must be taken to preserve the arterial and venous blood supply to the ureter by avoiding any dissection into the renal hilum. Aberrant renal arteries must be preserved or repaired if damaged. Ureteroneocystostomy is the preferred method for re-establishing urinary tract continuity following transplantation. The immediate surgical correction of urologic complications is mandatory, and the techniques involved are highly specialized and must be individualized with each patient.