TABLE 963 Key Physical Examination Elements for Renal Transplant Patients

ANCILLARY TESTS The workup for renal transplant patients with suspected infection should include routine testing ( Ta,bJ§...9§-4). Additional tests should be performed based on the patient's presenting complaint, history, and physical examination. Common sites of infection, such as the genitourinary and pulmonary tracts, should be evaluated in all patients with a urinalysis and chest radiograph. A complete blood count; determinations of electrolyte, blood urea nitrogen, and creatinine levels; and liver function tests, while rarely diagnostic, may provide clues to the infectious agent and assess function of the renal graft. A complete blood count may disclose a leukocytosis with a left shift, seen with bacterial infections, unless the immunosuppressive agents have depressed the bone marrow. In addition, leukopenia with an increase in atypical lymphocytes is commonly seen with viral infections, especially CMV. Liver function tests may show mild transaminase elevations with CMV and EBV infections. Much higher elevations of transaminase are associated with hepatitis B. Bacterial cultures of blood and urine should be obtained.

If indicated, blood, urine, other body fluids, and tissue can be obtained for bacterial, mycobacterial, viral, and fungal studies. Serologic studies are especially important for the diagnosis of a wide variety of viral, fungal, and parasitic infections. Renal graft ultrasound studies should be reserved for patients suspected of having urinary obstruction, pyelonephritis, perinephric abscess, urine leak, or wound infection. A very low index of suspicion should be maintained for lumbar puncture in transplant patients because of the high incidence of Listeria meningitis.

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