Hm, let’s wait a minute. This patient’s kidney function appears to be near the post-transplantation nadir. We might be able to perform some less invasive testing before subjecting this patient to an allograft biopsy.

In a patient with stable kidney function and diarrhea, this test is not the highest yield for an initial test. Try again!

In a patient with stable kidney function and diarrhea, this test is not the highest yield for an initial test. Try again!

Excellent! Diarrhea in an immunocompromied patient should raise suspicion for C. dificile colitis. The PCR test is negative.

Excellent! The donor and recipient’s CMV status can help us stratify the risk of CMV infection. Here, the donor’s CMV status is positive (CMV IgG +) while the recipient’s CMV status is CMV negative (CMV IgG -).

You call your GI colleagues and they advise you to continue your workup before subjecting this patient to an invasive colonoscopy. Keep going!

Excellent! Diarrhea in an immunocompromised patient should raise suspicion for a wide variety of pathogens. Viruses may include norovirus, sapovirus, astrovirus, adenovirus, and rotavirus. Parasites typically include Giardia lamblia, cryptosporidia, Cyclospora cayetanensis, Dientamoeba fragilis, Entamoeba histolytica and microsporidia.  The stool tests are negative.

BK viremia is typically asymptomatic. It may picked up on screening tests or in the setting of acute kidney injury and indicative of over immunosuppression. BK nephropathy can also present with pyuria and acute kidney injury.

Unfortunately, MPA trough levels do not correlate with adverse effects related to the drug. While diarrhea is a common adverse effect, this test will not help us distinguish between drug-related diarrhea and other etiologies.

Thus far, we haven’t seen any evidence of adenovirus infection. Adenovirus nephritis may present with hematuria and acute kidney injury.

Great choice, the combination of donor CMV IgG+ and a CMV IgG – recipient presents the highest risk for post-transplantation CMV infection. The serum CMV PCR is 1,237,082 IU/mL. Further, diarrhea in an immunocompromised patient should raise suspicion for CMV colitis.