Abstract: SA-PO1149
Emphysematous Pyelonephritis of a Kidney Allograft Complicated by Subcapsular Hematoma
Session Information
- Transplantation: Clinical - Infectious Diseases
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Pant, Abhishek, Stony Brook University Hospital, Stony Brook, New York, United States
- Santos, James Urbano, Stony Brook University Hospital, Stony Brook, New York, United States
- Kaur, Navdeep, Stony Brook University Hospital, Stony Brook, New York, United States
- Campbell, Sean R., Stony Brook University Hospital, Stony Brook, New York, United States
Introduction
Emphysematous Pyelonephritis (EPN) is an acute, necrotizing infection of the kidney associated with gas formation in renal parenchyma, collecting tissue or perinephric tissue. We report a rare case of EPN in a renal allograft complicated by subcapsular hematoma.
Case Description
A 61-year-old male with a history of coronary artery bypass grafting (6 months prior), on aspirin and clopidogrel, living-related renal transplant (21 years prior) with CKDIII and recurrent urinary tract infections, presented with left lower abdominal pain. He had prior biopsy-proven mild calcineurin inhibitor toxicity (16 years prior) and was maintained on sirolimus, tacrolimus, and mycophenolate mofetil. On presentation, vitals were stable; examination was notable for moderate left flank tenderness. CT abdomen showed a 10 cm hematoma surrounding the renal allograft with air in the collecting system and ureter, concerning EPN. Urine culture grew Klebsiella pneumoniae. Hospital course was complicated by severe acute kidney injury (creatinine 2.0 to 8.4 mg/dL over 3 days), persistent hyperkalemia, and anuria requiring hemodialysis. Repeat CT showed decreased gas but unchanged hematoma. Given worsening allograft function, he underwent surgical exploration of renal allograft on day 5 with evacuation of hematoma. Postoperatively, renal function improved, with creatinine decreasing to 6.3 mg/dL by postoperative day 6 and 4.9 mg/dL by day 14, without further dialysis.
Discussion
Spontaneous atraumatic subcapsular renal hematoma (Wunderlich syndrome) is a life-threatening condition, mostly associated with renal neoplasms, with infectious causes being rare. Our patient had class 4 EPN per the classification by Huang et al, which carries a high mortality risk. Isolation of Klebsiella pneumoniae from the drained fluid further supports an infectious etiology. EPN in renal allografts may rarely be complicated by subcapsular hematoma, limiting standard management of antimicrobials and drain placement. Early recognition and timely surgical intervention are critical to preserve graft function.
Air loculi in collecting system and renal subcapsular hematoma.