title: Fever, infection, and rejection after kidney transplant failure.
abstract: BACKGROUND
  Patients returning to dialysis therapy after renal transplant failure have high morbidity and retransplant rates. After observing frequent hospitalizations with fever after failure, it was hypothesized that maintaining immunosuppression for the failed allograft increases the risk of infection, while weaning immunosuppression can lead to symptomatic rejection mimicking infection.
  
  
  METHODS
  One hundred eighty-six patients with failed kidney transplants were analyzed for rates of hospitalization with fever within 6 months of allograft failure. Patients were stratified by the presence of full immunosuppression versus minimal (low-dose prednisone) or no immunosuppression, before hospital admission. Subsequent rates of documented infection and nephrectomy, as well as patient survival, were ascertained.
  
  
  RESULTS
  Hospitalization with fever within 6 months of allograft failure was common, occurring in 44% of patients overall. However, among febrile hospitalized patients who had been weaned off of immunosuppression before admission, only 38% had documented infection. In contrast, 88% of patients maintained on immunosuppression had documented infection (P<0.001). In both groups, dialysis catheter-related infections were the most common infection source. Allograft nephrectomy was performed in 81% of hospitalized patients with no infection, compared to 30% of patients with documented infection (P<0.001). Mortality risk was significantly higher in patients with concurrent pancreas transplants or who were hospitalized with documented infection.
  
  
  CONCLUSIONS
  Maintenance immunosuppression after kidney allograft failure was associated with a greater incidence of infection, while weaning of immunosuppression commonly resulted in symptomatic rejection with fever mimicking infection on presentation. Management of the failed allograft should include planning to avoid both infection and sensitizing events.
authors.affiliation: 1 Division of Transplant Surgery, Department of Surgery, Case Western Reserve University & University Hospitals Case Medical Center, Cleveland, Ohio. 2 Division of Nephrology, Department of Internal Medicine, Case Western Reserve University & University Hospitals Case Medical Center, Cleveland, Ohio. 3 Address correspondence to: Joshua J. Augustine, M.D., Division of Nephrology, Department of Internal Medicine, University Hospitals Case Medical Center, 11100 Euclid Avenue, LKS 5048, Cleveland, OH 44106.
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Woodside
authors.forename: Zachary W
authors.initials: ZW
authors.lastname: Schirm
authors.forename: Kelly A
authors.initials: KA
authors.lastname: Noon
authors.forename: Anne M
authors.initials: AM
authors.lastname: Huml
authors.forename: Aparna
authors.initials: A
authors.lastname: Padiyar
authors.forename: Edmund Q
authors.initials: EQ
authors.lastname: Sanchez
authors.forename: Nagaraju
authors.initials: N
authors.lastname: Sarabu
authors.forename: Donald E
authors.initials: DE
authors.lastname: Hricik
authors.forename: James A
authors.initials: JA
authors.lastname: Schulak
authors.forename: Joshua J
authors.initials: JJ
authors.lastname: Augustine
mesh_terms: D000328:Adult; D003141:Communicable Diseases / Q000209:etiology* / Q000401:mortality / Q000628:therapy; D004334:Drug Administration Schedule; D005260:Female; D005334:Fever / Q000209:etiology* / Q000401:mortality / Q000628:therapy; D006084:Graft Rejection / Q000209:etiology* / Q000401:mortality / Q000628:therapy; D006801:Humans; D007166:Immunosuppressive Agents / Q000008:administration & dosage / Q000009:adverse effects*; D053208:Kaplan-Meier Estimate; D016030:Kidney Transplantation / Q000009:adverse effects* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy; D016035:Pancreas Transplantation / Q000009:adverse effects; D010359:Patient Readmission; D006435:Renal Dialysis; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D013997:Time Factors; D017211:Treatment Failure
chemical_list: D007166:Immunosuppressive Agents