Fever and Gross Hematuria in a Kidney Transplant Recipient

Case DescriptionA 61-year-old man presented, 7 months after deceased donor kidney transplantation, with 4 days of fever, hematuria, and dysuria. His immunosuppression regimen included tacrolimus 1.5 mg twice daily, prednisone 5 mg daily, and mycophenolate mofetil 500 mg twice daily. He was febrile to 101.6 and had tenderness to palpation in the right lower quadrant over his graft site. His serum creatinine on admission was 1.4 mg/dl from a baseline of 1.0 mg/dl. White blood cell count was 4.4×103/ µ l with 85.9% neutrophils. Tacrolimus trough level was 13.3 ng/ml. Urinalysis demonstrated 100 mg/dl protein, 109 white blood cells per high-power field, 344 isomorphic red blood cells per high-power field, and hyaline casts. Urine and blood …