A 42-year-old man with diabetes on hemodialysis received a deceased donor kidney transplantation. Immunosuppression included anti-thymocyte globulin, methylprednisolone followed by tacrolimus, mycophenolate mofetil and prednisolone. A week later a biopsy done due to rising creatinine showed acute tubular necrosis from which he recovered and was discharged.   

Few days later he was admitted with fever, dry cough, lung nodules which responded to broad spectrum antibiotics.  

He was readmitted with fever, cough, purulent expectoration, hyperglycemia, klebsiella urine infection, reappearance of lung nodules and AKI requiring dialysis. Aspergillus was isolated from sputum.  

Learning objectives:

• Early postoperative graft dysfunction: approach to diagnosis
• Balancing net Immunosuppression and rejection risk.
• Improving organ allocation algorithm: minimize over immunosuppression, improve long term outcome