Kidney Transplant

A kidney transplant patient spikes a fever and their creatinine climbs 48 hours post-op — is it rejection or infection? Your assessment decides the next move.

Kidney transplantation is the definitive treatment for end-stage renal disease, offering superior survival and quality of life compared to dialysis. The transplanted kidney is placed in the iliac fossa (not the native kidney location), and the patient will have a surgical incision in the lower abdomen. Post-operatively, urine output is the most critical indicator of graft function — expect large volumes initially due to osmotic diuresis, then monitor for sudden decreases suggesting rejection or vascular complications. Acute rejection is the primary threat and can occur within days to months. Signs include fever, graft tenderness over the iliac fossa, decreased urine output, rising serum creatinine, hypertension, and weight gain from fluid retention. Any sustained rise in creatinine from baseline is significant and warrants prompt evaluation. Lifelong immunosuppression with agents like tacrolimus, mycophenolate, and corticosteroids is non-negotiable — missing even a few doses can trigger rejection. The nursing priority triad: strict I&O monitoring, infection prevention (immunosuppressed patients are profoundly vulnerable), and immunosuppressant adherence with trough-level monitoring. Tacrolimus trough levels are typically maintained at 8–12 ng/mL early post-transplant, then 5–8 ng/mL during maintenance.

Key Distinctions

Don't confuse acute rejection (fever, rising creatinine, graft tenderness, oliguria) with ATN/delayed graft function (gradual recovery of output without fever or tenderness). Students mix up the transplant kidney location — it's in the iliac fossa, not the flank. Infection and rejection look similar (both cause fever), but rejection adds graft-site tenderness and rising creatinine, while infection typically presents with a specific source (wound, pulmonary, urinary). Hyperacute rejection is distinct — it occurs within minutes to hours due to preformed antibodies and results in immediate graft loss.

Clinical Pearl

Transplant kidney lives low — iliac fossa, not the flank. Tenderness there plus rising creatinine equals rejection until proven otherwise.