Successful management of severe sepsis with respiratory failure following live renal transplantation

Janet Vasanthi1*, Leema Rebekal Rosy2, Esthar Rani3

1Nursing Incharge, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

2Assistant Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

3Nursing Superintendent, Kauvery Hospital, Tennur, Trichy, Tamil Nadu

*Correspondence

Abstract

Renal transplantation is the preferred treatment for end-stage renal disease, but post-transplant patients are at increased risk of severe infections due to immunosuppression. We report a case of a 59-year-old male with ESRD on maintenance haemodialysis who underwent live renal transplantation. The immediate postoperative period was uneventful with good graft function. However, the patient later developed severe sepsis with respiratory failure, graft dysfunction, and multi-organ involvement requiring intensive care management including mechanical ventilation, haemodialysis, and antimicrobial therapy. He also required tracheostomy and urological intervention. With timely multidisciplinary management and meticulous nursing care, the patient showed gradual recovery and was discharged in stable condition. This case highlights the importance of early recognition of sepsis, vigilant monitoring, and integrated critical care in post-transplant patients.

Keywords: Renal transplant; Sepsis; ARDS; Critical care; Immunosuppression; Fungal infection

Introduction

Renal transplantation remains the gold standard treatment for patients with ESRD, significantly improving survival and quality of life. However, post-transplant patients are highly susceptible to infections due to lifelong immunosuppressive therapy such as tacrolimus, mycophenolate mofetil, and steroids.

Sepsis is a major cause of morbidity and mortality in transplant recipients, often presenting atypically and progressing rapidly to multi-organ dysfunction. Early diagnosis, aggressive management, and multidisciplinary care are essential for improving outcomes.

Case presentation

A 59 year old male was diagnosed with ESRD on maintenance haemodialysis

Etiology: Chronic glomerulonephritis

Pre-Transplant evaluation

  • CDC crossmatch: Negative
  • Flow cytometry crossmatch: Negative
  • HLA compatibility: 4/16
  • Donor: Wife (AB+)

Surgical procedure

The patient underwent live renal transplantation on 11.12.2025.

Intraoperative details:

  • Left donor nephrectomy performed
  • Single renal artery, vein, and ureter

Anastomosis

  • Renal artery → Right external iliac artery
  • Renal vein → Right external iliac vein
  • Ureter implanted into bladder (non-refluxing technique)
  • DJ stent placed

Ischemia time

  • Warm: 4 min
  • Cold: 45 min

Postoperative course (initial phase)

  • Urine output: Adequate (up to 8300 ml/day initially)
  • Serum creatinine improved from 2.79 → 0.9 mg/dL
  • Doppler: Normal graft perfusion
  • Postoperative period: Uneventful

Complicated clinical course

After initial recovery, the patient presented with Fever, Cough with expectoration, Breathlessness, Decreased urine output

Clinical deterioration

Developed severe sepsis → septic shock

Required:

  • Mechanical ventilation
  • Inotropic support
  • ICU admission

Investigations

 

  • CT KUB: Renal calculi, ureteric obstruction
  • USG Abdomen: Hydroureteronephrosis
  • ECHO: Mild LV dysfunction (EF ~60%)
  • CT Brain: No acute pathology

Medical intervention

Management of severe Sspsis and septic shock

The patient was promptly initiated on broad-spectrum intravenous antibiotics after clinical suspicion of sepsis, following institutional sepsis protocol. Hemodynamic status was closely monitored, and intravenous fluids along with vasopressor support were administered to maintain adequate mean arterial pressure. Serial monitoring of sepsis markers, including inflammatory parameters and cultures, was performed to guide ongoing therapy and assess response to treatment.

Respiratory support and ARDS management

The patient was intubated and placed on mechanical ventilation due to worsening respiratory distress and hypoxia. Lung-protective ventilation strategies were implemented, including appropriate tidal volume and PEEP settings. Tracheostomy was performed to facilitate prolonged ventilatory support and improve airway management.

Renal support and graft function management

Renal function was closely monitored through serial serum creatinine levels and urine output measurements. Haemodialysis was initiated and continued as required to manage fluid overload and electrolyte imbalance. Immunosuppressive therapy (tacrolimus, mycophenolate mofetil, and steroids) was carefully adjusted to balance graft survival and infection risk.

Management of urological complications

Imaging studies identified renal calculi with obstructive uropathy contributing to infection. The patient underwent cystoscopy with DJ stent placement to relieve obstruction and improve urinary drainage. Post-procedural monitoring was performed to ensure adequate urine output and resolution of obstruction.

Antifungal therapy for secondary infection

The patient developed fungal infection (Candida), confirmed through culture reports. Appropriate antifungal therapy was initiated based on sensitivity patterns and continued for the recommended duration. Clinical response was monitored through resolution of fever and improvement in laboratory parameters.

Hemodynamic and cardiovascular monitoring

Continuous monitoring of blood pressure, heart rate, and perfusion parameters was performed in the ICU setting. Inotropic support was administered and titrated based on hemodynamic response. Echocardiography was performed, revealing mild left ventricular dysfunction, and appropriate supportive care was provided.

Post-Transplant immunosuppressive management

The patient was maintained on standard immunosuppressive therapy, including tacrolimus, mycophenolate mofetil, and corticosteroids. Drug levels (e.g., tacrolimus levels) were monitored and adjusted to prevent rejection while minimizing infection risk. Close monitoring was done for signs of graft rejection and drug-related complications.

Supportive and multidisciplinary care

The patient received comprehensive ICU care involving nephrology, critical care, and urology teams. Nutritional support, electrolyte correction, and metabolic stabilization were provided throughout the hospital stay. Gradual weaning from ventilatory and hemodynamic support was achieved as the patient’s condition improved.

Outcome

The patient showed gradual clinical improvement following aggressive multidisciplinary management, including ventilatory support, hemodialysis, antimicrobial therapy, and urological intervention. Respiratory status improved significantly, allowing successful weaning from mechanical ventilation and subsequent stabilization of oxygen saturation on room air. Hemodynamic parameters stabilized with resolution of septic shock, and inotropic support was gradually tapered and discontinued.

Renal function showed improvement, with adequate urine output and stabilization of serum creatinine levels, although the patient required ongoing maintenance haemodialysis. Infectious parameters improved with resolution of fever and control of fungal infection following appropriate antimicrobial and antifungal therapy. The patient’s general condition improved, and he became hemodynamically stable, conscious, and oriented at the time of discharge. He was discharged with advice for regular follow-up, continuation of immunosuppressive therapy, dialysis support, and close monitoring for recurrence of infection or graft dysfunction.

Discussion

Renal transplantation is the preferred treatment for end-stage renal disease (ESRD), offering improved survival and quality of life compared to long-term dialysis. However, post-transplant patients remain highly vulnerable to infections due to lifelong immunosuppressive therapy, which alters host immune responses and predisposes them to both common and opportunistic infections.

In the present case, the patient initially demonstrated good graft function with adequate urine output and declining serum creatinine levels, indicating a successful surgical and immediate postoperative outcome. However, the subsequent development of severe sepsis highlights the unpredictable and rapid deterioration that can occur in immunocompromised individuals. In transplant recipients, infections often present atypically and can progress quickly to septic shock and multi-organ dysfunction, as seen in this patient. Respiratory failure in this case was likely multifactorial, with contributions from severe infection, systemic inflammatory response, and possible fluid overload. The development of ARDS necessitated mechanical ventilation and advanced critical care support. Early initiation of lung-protective ventilation strategies and timely tracheostomy played a key role in facilitating prolonged respiratory management and eventual recovery.

Urological complications, including renal calculi and obstructive uropathy, further contributed to the patient’s clinical deterioration. Obstruction of urinary flow can act as a nidus for infection, particularly in immunosuppressed patients, leading to persistent or recurrent sepsis. The timely identification and management of obstruction through cystoscopy and DJ stenting were crucial in controlling the source of infection. Another significant aspect of this case was the development of fungal infection, specifically candidiasis, which is commonly seen in critically ill and immunocompromised patients. The use of broad-spectrum antibiotics, prolonged ICU stay, and invasive devices increase the risk of opportunistic infections. Early initiation of antifungal therapy based on culture reports contributed to infection control and improved outcomes.

Renal graft dysfunction observed during the course of illness may have been multifactorial, including sepsis-related acute kidney injury, hemodynamic instability, and possible drug-related nephrotoxicity. The need for hemodialysis underscores the severity of organ dysfunction in such cases. Careful adjustment of immunosuppressive therapy was essential to balance the risk of rejection with the need to control infection. This case also underscores the importance of a multidisciplinary approach in managing complex post-transplant complications. Collaboration between nephrology, critical care, urology, and infectious disease teams ensured comprehensive management of the patient. Equally important was the role of nursing care, which included continuous monitoring, infection prevention, ventilator management, and supportive care. Early recognition of clinical deterioration by nursing staff and timely communication with the medical team were pivotal in guiding interventions.

This case aligns with studies indicating that infections remain a leading cause of morbidity and mortality in renal transplant recipients, particularly within the early post-transplant period. However, the combination of severe sepsis, ARDS, fungal infection, and obstructive uropathy in a single patient highlights the complexity and rarity of such presentations.

Conclusion

This case highlights that even after a technically successful renal transplantation, patients remain at significant risk for life-threatening infections due to immunosuppression. Early recognition of sepsis, prompt initiation of appropriate antimicrobial therapy, and aggressive intensive care management are crucial in preventing progression to multi-organ failure. A multidisciplinary approach involving nephrology, critical care, urology, and nursing teams plays a vital role in improving patient outcomes. Additionally, vigilant nursing care, continuous monitoring, and timely interventions significantly contribute to recovery. This case emphasizes the importance of close post-transplant surveillance and early intervention strategies to reduce morbidity and mortality in renal transplant recipients.

Key learning points

  • Post-transplant patients are highly infection-prone
  • Sepsis can rapidly progress to multi-organ failure
  • Early ICU intervention saves lives
  • Nursing care is crucial in recovery

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment