Last reviewed: March 2026
Contents
MDM Templates
Renal Transplant — General
Patient presents with *** in the setting of renal transplant (*** post-transplant, on ***). Given transplant history, considered increased risk for acute rejection, vascular occlusion, obstructive uropathy, opportunistic infection, and immunosuppressant-related complications including nephrotoxicity, electrolyte derangement, and cardiovascular disease. Patient is well appearing. History, exam, and workup do not suggest acute rejection, surgical complication, or serious infection.
Plan: Discussed with transplant nephrology. Disposition: Discharge with transplant team follow-up. Return precautions for fever, decreased urine output, graft site pain/swelling, or worsening symptoms.
Renal Transplant — Rejection
Patient presents with fever, graft tenderness, and rising creatinine concerning for acute allograft rejection. History, exam, and workup lower suspicion for surgical complication (vascular occlusion, urinary leak, obstruction), infection, and calcineurin inhibitor nephrotoxicity.
Transplant nephrology consulted emergently regarding need for biopsy and immunosuppression adjustment. Renal ultrasound obtained to evaluate graft perfusion and exclude obstruction or perinephric collection. Disposition: Admit.
Renal Transplant — Early Surgical Complication
Patient presents *** post-transplant with ***. In the early post-transplant period, considered vascular occlusion (renal artery or vein thrombosis), peritransplant hematoma, urinary leak, and lymphocele. Renal ultrasound with Doppler obtained to evaluate graft perfusion and perinephric collections.
If vascular occlusion suspected: Transplant surgery consulted emergently. Acute vascular occlusion in the early post-transplant period is a surgical emergency.
If hematoma/collection identified: Transplant surgery consulted regarding need for intervention.
Renal Transplant — Fever
Patient presents with fever in the setting of renal transplant. Immunosuppressed patients are at risk for both typical community-acquired infections and opportunistic pathogens. Given timing *** post-transplant, considered opportunistic infections including CMV, fungal, and atypical pathogens in addition to standard bacterial sources.
Broad workup obtained. Transplant nephrology consulted. Disposition: Admit for further workup — fever in the first year post-transplant generally warrants inpatient evaluation.
Clinical Education
Timeline of Complications
| Time Period | Key Complications |
| First week | Vascular occlusion (renal artery/vein thrombosis), hyperacute rejection, hematoma |
| 1–4 weeks | Urinary leak, acute cellular rejection, wound infection |
| 1–6 months | CMV and opportunistic infections, acute rejection, lymphocele |
| >6 months | Chronic rejection, calcineurin inhibitor nephrotoxicity, cardiovascular disease, malignancy |
Acute Rejection
Classic triad: fever + allograft tenderness + AKI — but presentation can be subtle.[3] Biopsy is the gold standard (Banff classification).
Calcineurin inhibitor nephrotoxicity can mimic rejection — both cause rising creatinine. CNI drug levels are unreliable in the ED (best drawn 1–3 hours before a scheduled dose). Don’t try to distinguish rejection from nephrotoxicity in the ED — consult transplant nephrology and let them sort it out.
Surgical Complications
Vascular occlusion: First week post-transplant. Acute renal failure with oligoanuria — this is a surgical emergency requiring emergent transplant surgery consultation.
Peritransplant hematoma: Early post-transplant, associated with perioperative anticoagulation. Presents with severe pain over the allograft, falling hemoglobin, and rising creatinine.
Urinary leak: Disruption of the ureteric-bladder anastomosis. Pain, decreased output, perinephric fluid on ultrasound.
Lymphocele: Within first 3 months from severed lymphatics during transplant surgery. Large lymphoceles can cause graft pain, AKI, urinary frequency, ipsilateral leg edema, iliac vein thrombosis, or PE.
Obstructive uropathy: Ureteric stricture or lymphocele compression. Hydronephrosis on ultrasound may require nephrostomy tube placement.
Infections in Renal Transplant
CMV is the most common opportunistic infection — fever, elevated LFTs, leukopenia in first 6 months. Diagnose with PCR.[4]
Fever in the first year post-transplant generally warrants admission. Highest OI risk is between months 2–6 post-transplant.
BK virus nephropathy: Rising creatinine, diagnosed by PCR — can mimic rejection. Important to consider in patients with unexplained graft dysfunction.[2]
Standard infections still occur — UTI is very common in renal transplant patients. Don’t anchor on exotic diagnoses when the presentation is straightforward.
Drug Interactions and Side Effects
AVOID macrolides (azithromycin, clarithromycin) — CYP3A4 inhibition increases calcineurin inhibitor levels. Also avoid azole antifungals, diltiazem, verapamil, and amiodarone for the same reason.[5]
Calcineurin inhibitor side effects: Nephrotoxicity, hyperkalemia, hypomagnesemia, tremor, new-onset diabetes.
Corticosteroid complications: Osteoporosis, avascular necrosis, tendon rupture (Achilles, quadriceps), glucose intolerance.
Cardiovascular risk is 3–5× higher — lower threshold for ACS workup. Immunosuppressants interfere with some cardiac drugs (diltiazem, verapamil, amiodarone).
Safe antibiotics: Fluoroquinolones, beta-lactams, TMP-SMX (but monitor potassium with concurrent CNIs).[1]
References
- KDIGO Transplant Work Group. KDIGO clinical practice guideline for the care of kidney transplant recipients. Am J Transplant. 2009;9(Suppl 3):S1-155. PubMed
- Sawinski D, Blumberg E. Infection in renal transplant recipients. Infect Dis Clin North Am. 2019;33(2):431-449.
- Nankivell BJ, Alexander SI. Rejection of the kidney allograft. N Engl J Med. 2010;363(15):1451-1462. PubMed
- Fishman JA. Infection in organ transplantation. Am J Transplant. 2017;17(4):856-879. PubMed
- Halloran PF. Immunosuppressive drugs for kidney transplantation. N Engl J Med. 2004;351(26):2715-2729. PubMed
tydotphrase.com 