Ten days after a kidney transplant, a 32-year-old man returns to the hospital with symptoms of fever, and decreased urine output. He reports no cough, sputum, or dysuria. An ultrasound of the transplant kidney shows allograft enlargement. Which of the following is the most likely diagnosis?
First, I need to consider the time frame. Ten days post-transplant is a critical period for certain complications. Early complications like acute rejection or acute tubular necrosis (ATN) come to mind. However, the ultrasound shows allograft enlargement, which might hint at something else. Also, there's a fever, which could indicate infection. But the patient doesn't have symptoms like cough or dysuria, which might point to a urinary tract infection or pneumonia.
Acute rejection is a common cause of allograft dysfunction in the early post-transplant period. The symptoms include fever, graft tenderness, decreased urine output, and allograft enlargement. The ultrasound finding here is consistent with this. In contrast, ATN usually doesn't present with fever and the allograft might not be enlarged. Infections can cause fever, but without localized symptoms and given the timing, acute rejection is more likely.
Now, looking at the options (though they're not listed here), the correct answer would likely be acute rejection. The other options might include ATN, infection, or other causes. The key differentiators are the fever, allograft enlargement, and timing.
**Core Concept**
This question tests the differential diagnosis of allograft dysfunction in the early post-transplant period. Key principles include the timing of complications (e.g., acute rejection within the first month), imaging findings (e.g., allograft enlargement in rejection), and clinical features like fever and oliguria.
**Why the Correct Answer is Right**
Acute cellular rejection is the most likely diagnosis. It typically occurs within the first month post-transplant, presenting with fever, graft tenderness, oliguria, and allograft enlargement on ultrasound. The immune response leads to T-cell-mediated injury of the transplanted kidney, causing inflammation and reduced function. Unlike infections or ATN, rejection in this timeframe is strongly associated with these findings.
**Why Each Wrong Option is Incorrect**
**Option A:** Acute tubular necrosis (ATN) usually occurs in the first week post-transplant and is caused by ischemia or nephrotoxins. It lacks fever and allograft enlargement.
**Option B:** Urinary tract infection (UTI) would present with dysuria, suprapubic pain, or pyuria, which are absent here.
**Option C:** Pneumonia would present with respiratory symptoms (cough, sputum), not renal symptoms.
**Clinical Pearl / High-Yield Fact**
Acute rejection in the first month post-transplant is a classic exam trap—students often confuse it with ATN. Remember: **fever + allograft enlargement + oliguria = rejection**. A biopsy is the gold standard for confirmation.
**Correct Answer: C. Acute cellular rejection**