Skip to main content

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

  • Review Article
  • Published:

Urinary tract infection in the renal transplant patient

Nature Clinical Practice Nephrology volume 4, pages 252–264 (2008)Cite this article

Abstract

Urinary tract infection (UTI) is the most common type of bacterial infection contracted by recipients of renal allografts in the post-transplantation period. Fungi and viruses can also cause UTIs, but infections caused by these organisms are less common than those caused by bacteria. Both the lower and upper urinary tract (encompassing grafted or native kidneys) can be affected. Factors that might contribute to the development of UTIs include excessive immunosuppression, and instrumentation of the urinary tract (e.g. urethral catheters and ureteric stents). Antimicrobials are the mainstays of treatment and should be accompanied by minimization of immunosuppression when possible. The use of long-term antimicrobial prophylaxis is controversial, however, as it might increase the likelihood of infective organisms becoming resistant to treatment. There are conflicting data on the associations of post-transplantation UTI with graft and patient survival.

Key Points

  • Urinary tract infection (UTI) is the most common bacterial infection in the period after renal transplantation; the infection can develop early (within 6 months of the procedure) or late (more than 6 months after transplantation)

  • Excessive immunosuppression might be a key factor in the development of both early and late UTI; early UTI might also be caused by instrumentation of the urinary tract (e.g. urethral catheters and ureteric stents)

  • Fungal and viral infections are less common than bacterial UTIs but require active management

  • Post-transplantation UTI should be treated with antimicrobials, and by reducing immunosuppression when appropriate

  • Upper UTI (i.e. pyelonephritis) of either transplanted or native kidneys should be treated aggressively, and any underlying cause detected

  • The use of long-term antimicrobial prophylaxis is controversial and could increase the risk of bacterial resistance to treatment

  • Transplant pyelonephritis, as opposed to lower tract UTI, might be associated with decreased long-term graft function

This is a preview of subscription content, access via your institution

Access options

Buy this article

  • Purchase on Springer Link
  • Instant access to full article PDF
Buy now

Prices may be subject to local taxes which are calculated during checkout

Similar content being viewed by others

References

  1. Alangaden GJ et al. (2006) Infectious complications after kidney transplantation: current epidemiology and associated risk factors. Clin Transplant 20: 401–409

    Article  Google Scholar 

  2. Dantas SR et al. (2006) Nosocomial infections in renal transplant patients: risk factors and treatment implications associated with urinary tract and surgical site infections. J Hosp Infect 63: 117–123

    Article  CAS  Google Scholar 

  3. Valera B et al. (2006) Epidemiology of urinary infections in renal transplant recipients. Transplant Proc 38: 2414–2415

    Article  CAS  Google Scholar 

  4. Burgos Revilla FJ et al. (1999) Renal transplantation and urinary infection: review [Spanish]. Actas Urol Esp 23: 95–104

    CAS  PubMed  Google Scholar 

  5. Prát V et al. (1985) Urinary tract infection in renal transplant patients. Infection 13: 207–210

    Article  Google Scholar 

  6. Wagener MM and Yu VL (1992) Bacteremia in transplant recipients: a prospective study of demographics, etiologic agents, risk factors, and outcomes. Am J Infect Control 20: 239–247

    Article  CAS  Google Scholar 

  7. Renoult E et al. (1992) Urinary tract infections during the 1st month after kidney transplantation [French]. Agressologie 33: 147–150

    PubMed  Google Scholar 

  8. Senger SS et al. (2007) Urinary tract infections in renal transplant recipients. Transplant Proc 39: 1016–1017

    Article  CAS  Google Scholar 

  9. Muñoz P (2001) Management of urinary tract infections and lymphocele in renal transplant recipients. Clin Infect Dis 33 (Suppl 1): S53–S57

    Article  Google Scholar 

  10. Abbott KC et al. (2004) Late urinary tract infection after renal transplantation in the United States. Am J Kidney Dis 44: 353–362

    Article  Google Scholar 

  11. Abbott KC et al. (2001) Hospitalizations for bacterial septicemia after renal transplantation in the United States. Am J Nephrol 21: 120–127

    Article  CAS  Google Scholar 

  12. Foley RN et al. (2004) Septicemia in the United States dialysis population, 1991 to 1999. J Am Soc Nephrol 15: 1038–1045

    Article  Google Scholar 

  13. Brennan DC et al. (2006) Rabbit antithymocyte globulin versus basiliximab in renal transplantation. N Engl J Med 355: 1967–1977

    Article  CAS  Google Scholar 

  14. Stamm WE (1991) Catheter-associated urinary tract infections: epidemiology, pathogenesis, and prevention. Am J Med 91 (Suppl 2): S65–S71

    Article  Google Scholar 

  15. Rabkin DG et al. (1998) Early catheter removal decreases incidence of urinary tract infections in renal transplant recipients. Transplant Proc 30: 4314–4316

    Article  CAS  Google Scholar 

  16. Brosnahan J et al. Types of urethral catheters for management of short-term voiding problems in hospitalised adults. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD004013. 10.1002/14651858.CD004013.pub2

  17. Anderson GG et al. (2003) Intracellular bacterial biofilm-like pods in urinary tract infections. Science 301: 105–107

    Article  CAS  Google Scholar 

  18. Kucheria R et al. (2004) Urinary tract infections: advances and new therapies. BJU Int 93: 690–691

    Article  CAS  Google Scholar 

  19. Wilson CH et al. Routine intraoperative ureteric stenting for kidney transplant recipients. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD004925. 10.1002/14651858.CD004925.pub2

  20. Casale P et al. (2005) Recurrent urinary tract infection in the post-transplant reflux nephropathy patient: is reflux in the native ureter the culprit? Pediatr Transplant 9: 324–327

    Article  Google Scholar 

  21. Pellé G et al. (2007) Acute pyelonephritis represents a risk factor impairing long-term kidney graft function. Am J Transplant 7: 899–907

    Article  Google Scholar 

  22. Bantar C et al. (1993) Clinical, epidemiologic, and microbiologic study of urinary infection in patients with renal transplant at a specialized center in Argentina [Spanish]. Arch Esp Urol 46: 473–477

    CAS  PubMed  Google Scholar 

  23. Rodman JS (1999) Struvite stones. Nephron 81 (Suppl 1): S50–S59

    Article  Google Scholar 

  24. Goya N et al. (1997) Prevalence of urinary tract infection during outpatient follow-up after renal transplantation. Infection 25: 101–105

    Article  CAS  Google Scholar 

  25. Dadhania D et al. (2003) Molecular signatures of urinary cells distinguish acute rejection of renal allografts from urinary tract infection. Transplantation 75: 1752–1754

    Article  Google Scholar 

  26. John U et al. (2006) High prevalence of febrile urinary tract infections after paediatric renal transplantation. Nephrol Dial Transplant 21: 3269–3274

    Article  Google Scholar 

  27. Krcmery S et al. (1999) Fungal urinary tract infections in patients at risk. Int J Antimicrob Agents 11: 289–291

    Article  CAS  Google Scholar 

  28. Hirsch HH (2002) Polyomavirus BK nephropathy: a (re-)emerging complication in renal transplantation. Am J Transplant 2: 25–30

    Article  Google Scholar 

  29. Giral M et al. (2002) Acute graft pyelonephritis and long-term kidney allograft outcome. Kidney Int 61: 1880–1886

    Article  Google Scholar 

  30. Sobh MA et al. (1992) Impact of schistosomiasis on patient and graft outcome after kidney transplantation. Nephrol Dial Transplant 7: 858–864

    CAS  PubMed  Google Scholar 

  31. Mahmoud KM et al. (2001) Impact of schistosomiasis on patient and graft outcome after renal transplantation: 10 years' follow-up. Nephrol Dial Transplant 16: 2214–2221

    Article  CAS  Google Scholar 

  32. Van der Weide MJ et al. (2006) Lower urinary tract symptoms after renal transplantation in children. J Urol 175: 297–302

    Article  Google Scholar 

  33. Herthelius M and Oborn H (2007) Urinary tract infections and bladder dysfunction after renal transplantation in children. J Urol 177: 1883–1886

    Article  Google Scholar 

  34. Dunn SP et al. (1987) Pyelonephritis following pediatric renal transplant: increased incidence with vesicoureteral reflux. J Pediatr Surg 22: 1095–1099

    Article  CAS  Google Scholar 

  35. Basiri A et al. (2006) Does pre-transplantation antireflux surgery eliminate post-renal transplantation pyelonephritis in children. J Urol 175: 1490–1492

    Article  CAS  Google Scholar 

  36. Dharnidharka VR et al. (2007) Effects of urinary tract infection on outcomes after renal transplantation in children? Clin J Am Soc Nephrol 2: 100–106

    Article  Google Scholar 

  37. Sadeghi M et al. (2005) Strong inflammatory cytokine response in male and strong anti-inflammatory response in female kidney transplant recipients with urinary tract infection. Transpl Int 18: 177–185

    Article  CAS  Google Scholar 

  38. Fowlis GA et al. (1994) The cost effectiveness of combined rapid tests (Multistix) in screening for urinary tract infections. JR Soc Med 87: 681–682

    CAS  Google Scholar 

  39. Hariharan S (2006) BK virus nephritis after renal transplantation. Kidney Int 69: 655–662

    Article  CAS  Google Scholar 

  40. Gonzalez-Michaca L et al. (2000) Percutaneous kidney biopsy, analysis of 26 years: complication rate and risk factors [Spanish]. Rev Invest Clin 52: 125–131

    CAS  PubMed  Google Scholar 

  41. Naber KG et al. (2006) Section 4. In European Association of Urology Guidelines on the management of Urinary and Male Genital Tract Infections 2006, 52–63. Amsterdam: Elsevier

    Google Scholar 

  42. Vogt P et al. (1988) Ofloxacin in the treatment of urinary tract infection in renal transplant recipients. Infection 16: 175–178

    Article  CAS  Google Scholar 

  43. Grekas D et al. (1993) Treatment of urinary tract infections with ciprofloxacin after renal transplantation. Int J Clin Pharmacol Ther Toxicol 31: 309–311

    CAS  PubMed  Google Scholar 

  44. Lazinska B et al. (2005) Bacteriological urinalysis in patients after renal transplantation. Pol J Microbiol 54: 317–321

    CAS  PubMed  Google Scholar 

  45. Schwab SJ et al. (1987) Renal infection in autosomal dominant polycystic kidney disease. Am J Med 82: 714–718

    Article  CAS  Google Scholar 

  46. Jepson RG et al. Cranberries for preventing urinary tract infections. Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD001321. 10.1002/14651858.CD001321.pub4

  47. Raz R et al. (2004) Cranberry juice and urinary tract infection. Clin Infect Dis 38: 1413–1419

    Article  CAS  Google Scholar 

  48. Raz R and Stamm WE (1993) A controlled trial of intravaginal estriol in postmenopausal women with recurrent urinary tract infections. N Engl J Med 329: 753–756

    Article  CAS  Google Scholar 

  49. Boedeker KS and Kilzer WJ (2001) Fluconazole dose recommendation in urinary tract infection. Ann Pharmacother 35: 369–372

    Article  CAS  Google Scholar 

  50. Siu YP et al. (2004) Successful kidney re-transplantation in a patient with previous allograft kidney tuberculosis. Transpl Infect Dis 6: 132–135

    Article  CAS  Google Scholar 

  51. Rice JC et al. (2006) Renal allograft injury is associated with urinary tract infection caused by Escherichia coli bearing adherence factors. Am J Transplant 6: 2375–2383

    Article  CAS  Google Scholar 

  52. Ciszek M et al. (2006) Urine cytokines profile in renal transplant patients with asymptomatic bacteriuria. Transplantation 81: 1653–1657

    Article  CAS  Google Scholar 

  53. Valente JF et al. (2003) Comparison of sirolimus vs. mycophenolate mofetil on surgical complications and wound healing in adult kidney transplantation. Am J Transplant 3: 1128–1134

    Article  CAS  Google Scholar 

  54. Rozanski J et al. (2005) Pretransplant nephrectomy in patients with autosomal dominant polycystic kidney disease. Transplant Proc 37: 666–668

    Article  CAS  Google Scholar 

  55. Khosroshahi HT et al. (2006) Efficacy of high-dose trimethoprim-sulfamethoxazol prophylaxis on early urinary tract infection after renal transplantation. Transplant Proc 38: 2062–2064

    Article  CAS  Google Scholar 

  56. Tolkoff-Rubin NE et al. (1982) A controlled study of trimethoprim-sulfamethoxazole prophylaxis of urinary tract infection in renal transplant recipients. Rev Infect Dis 4: 614–618

    Article  CAS  Google Scholar 

  57. Kaminska W et al. (2002) Urinary tract infections caused by endemic multi-resistant Enterobacter cloacae in a dialysis and transplantation unit. J Hosp Infect 51: 215–220

    Article  CAS  Google Scholar 

  58. Zárate G and Nader-Macias ME (2006) Influence of probiotic vaginal lactobacilli on in vitro adhesion of urogenital pathogens to vaginal epithelial cells. Lett Appl Microbiol 43: 174–180

    Article  Google Scholar 

  59. Osset J et al. (2001) Assessment of the capacity of Lactobacillus to inhibit the growth of uropathogens and block their adhesion to vaginal epithelial cells. J Infect Dis 183: 485–491

    Article  CAS  Google Scholar 

  60. Uehara S et al. (2006) A pilot study evaluating the safety and effectiveness of Lactobacillus vaginal suppositories in patients with recurrent urinary tract infection. Int J Antimicrob Agents 28 (Suppl 1): S30–S34

    Article  CAS  Google Scholar 

  61. Rayes N et al. (2005) Supply of pre- and probiotics reduces bacterial infection rates after liver transplantation—a randomized, double-blind trial. Am J Transplant 5: 125–130

    Article  Google Scholar 

  62. Lee SJ et al. (2007) Probiotics prophylaxis in children with persistent primary vesicoureteral reflux. Pediatr Nephrol 22: 1315–1320

    Article  Google Scholar 

  63. Land MH et al. (2005) Lactobacillus sepsis associated with probiotic therapy. Pediatrics 115: 178–181

    Article  Google Scholar 

  64. Nicolle LE et al. (2005) Infectious Diseases Society of America guidelines for the diagnosis and treatment of asymptomatic bacteriuria in adults. Clin Infect Dis 40: 643–654

    Article  Google Scholar 

  65. Olszyna DP et al. (2001) Urine interleukin-8 is a marker for urinary tract infection in postoperative patients. Infection 29: 274–277

    Article  CAS  Google Scholar 

  66. Boelke E et al. (2001) Urinary endotoxin excretion and urinary tract infection following kidney transplantation. Transpl Int 14: 307–310

    Article  CAS  Google Scholar 

  67. Blazik M et al. (2005) Leukocyte phenotype and function predicts infection risk in renal transplant recipients. Nephrol Dial Transplant 20: 2226–2230

    Article  Google Scholar 

  68. Yannaraki M et al. (2006) Urinary cytotoxic molecular markers for a noninvasive diagnosis in acute renal transplant rejection. Transpl Int 19: 759–768

    Article  CAS  Google Scholar 

  69. Smith SD et al. (2000) Temporal changes of cytokines and nitric oxide products in urine from renal transplant patients. Kidney Int 58: 829–837

    Article  CAS  Google Scholar 

  70. Light JA et al. (1980) Serum beta-2-microglobulin: an adjunctive monitoring test in renal transplantation. Proc Clin Dial Transplant Forum 10: 67–73

    CAS  PubMed  Google Scholar 

  71. Alexopoulos E et al. (1985) Urinary tract infections after renal transplantation. Drugs Exp Clin Res 11: 101–105

    CAS  PubMed  Google Scholar 

  72. Kuriyama M et al. (1991) Urinary tract infections after kidney transplantation [Japanese]. Hinyokika Kiyo 37: 1173–1179

    CAS  PubMed  Google Scholar 

  73. Takai K et al. (1998) Urinary tract infections following renal transplantation. Clin Transplant 12: 19–23

    CAS  PubMed  Google Scholar 

  74. Lyerová L et al. (2001) Urinary tract infection in patients with urological complications after renal transplantation with respect to long-term function and allograft survival. Ann Transplant 6: 19–20

    PubMed  Google Scholar 

  75. Kass EH (1956) Asymptomatic infections of the urinary tract. Trans Assoc Am Physicians 69: 56–64

    CAS  PubMed  Google Scholar 

  76. Stamm WE (1988) Protocol for diagnosis of urinary tract infection: reconsidering the criterion for significant bacteriuria. Urology 32 (Suppl 2): S6–S12

    Google Scholar 

  77. Lansang MC et al. (2006) The relationship between diabetes and infectious hospitalizations in renal transplant recipients. Diabetes Care 29: 1659–1660

    Article  Google Scholar 

  78. Grenier J et al. (2006) Pomelo juice, but not cranberry juice, affects the pharmacokinetics of cyclosporine in humans. Clin Pharmacol Ther 79: 255–262

  79. Kaim AH et al. (2001) PET-CT-guided percutaneous puncture of an infected cyst in autosomal dominant polycystic kidney disease: case report. Radiology 221: 818–821

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. RM de Souza is a Medical Student at King's College and J Olsburgh is a Consultant Transplant and Urological Surgeon at Guy's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,

    Ruth M de Souza & Jonathon Olsburgh

Authors
  1. Ruth M de Souza
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Jonathon Olsburgh
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Jonathon Olsburgh.

Ethics declarations

Competing interests

The authors declare no competing financial interests.

Rights and permissions

Reprints and permissions

About this article

Cite this article

de Souza, R., Olsburgh, J. Urinary tract infection in the renal transplant patient. Nat Rev Nephrol 4, 252–264 (2008). https://doi.org/10.1038/ncpneph0781

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1038/ncpneph0781

This article is cited by

Search

Advanced search

Quick links

Nature Briefing

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Get the most important science stories of the day, free in your inbox. Sign up for Nature Briefing