The Role of Host Factors and Bacterial Virulence Genes in

the Development of Pyelonephritis Caused by Escherichia

coli in Renal Transplant Recipients
Priscila Reina Siliano, Lillian Andrade Rocha, José Osmar Medina-Pestana, and
Ita Pfeferman Heilberg
Nephrology Division, Federal University of São Paulo, São Paulo, Brazil

Background and objectives: The aim of this study was to determine the role of host factors and bacterial virulence genes in
the development of pyelonephritis caused by Escherichia coli in renal transplant (Tx) recipients.
Design, setting, participants, & measurements: A total of 328 E. coli isolates from cases of cystitis (Cys; n ⴝ 239) or
pyelonephritis (PN; n ⴝ 89), with 169 from renal Tx recipients, were subjected to molecular analyses to identify P-fimbria
subunits (PapC, PapG II, and PapGIII), G- and M-fimbriae, and aerobactin. The presence of antibiotic resistance was also
determined. Parameters such as gender, age, immunosuppression regimens, causes of ESRD, kidney donor, intraoperative
anastomosis, use of double J stent, trimethoprim/sulfamethoxazole (TMP/SMZ) prophylaxis, and time after Tx were evaluated.
Results: A multivariate analysis showed a significant association between PN and renal Tx. In renal Tx recipients, the risk
of occurrence of PN was significantly higher among males and for those no longer receiving TMP/SMZ prophylaxis. E. coli
strains isolated from PN presented a lower prevalence of papGIII and lower rates of resistance to pipemidic acid. Although
papGII was more prevalent in PN than in Cys, it was not independently associated with PN.
Conclusions: These findings suggested that renal Tx increases the risk for PN, and the male sex represented a host factor
independently associated with risk, whereas the prophylaxis with TMP/SMZ was protective. The lack of papGIII and low
resistance to first-generation quinolones were bacterial-independent risk factors for PN in Tx.
Clin J Am Soc Nephrol 5: 1290 –1297, 2010. doi: 10.2215/CJN.06740909

U
rinary tract infections (UTIs) are one of the most
common infectious diseases encountered in clinical
practice. Especially in the setting of renal transplan-
tation, asymptomatic bacteriuria or symptomatic forms such as
cystitis (Cys) and pyelonephritis (PN) account for approxi-
mately 47% of infectious complications (1) and up to 60% of
bacteremias (2). The development of UTIs depends on anatom-
ical factors, the integrity of host defense mechanisms, and the
virulence of the infecting organisms (3). Potential predisposing
host factors in renal allograft recipients include immunosup-
pression, female sex, diabetes mellitus, urinary tract abnormal-
ities, and urinary stents, among others (4).
Escherichia coli is the most common gram-negative microor-
ganism identified in UTIs, even in transplanted patients (5,6).
Uropathogenic E. coli adhere to uroepithelial cells through fim-
brial adhesins, including type I, P-, M-, and G-fimbriae, and
adherence is one of the most important steps in the develop-
ment of UTIs (7). P-fimbria, composed of several protein sub-
units and encoded by pap (PN-associated pili) genes, is mostly
associated with acute PN (8). PapG adhesins at the tip of
Received September 22, 2009. Accepted March 30, 2010.
P-fimbriae mediate specific binding to glycolipid receptors on
the uroepithelia and renal tissue; three molecular variants of
PapG have been identified (9,10). PapGII (11,12) and PapC
(5,13) are suggested to be associated with upper UTI (PN),
whereas PapGIII predominates in lower UTI (Cys) (14). In
addition to adhesins, other virulence factors (i.e., aerobactin,
hemolysin, and capsular polysaccharide) may be associated
with the clinical manifestations of PN (12,13,15).
The acquisition of antibiotic resistance may be associated
with phenotypic changes in bacteria that render them more
virulent (16). On the other hand, other investigators have sug-
gested that quinolone resistance involves a genotypic change
associated with the loss of virulence factors in E. coli (17–20).
The aim of the study presented here was to evaluate the
association of host and bacterial virulence factors with the
development of PN by E. coli in renal transplant recipients.
Materials and Methods
Three-hundred ninety-six E. coli isolates from adult patients with
UTIs referred to the Microbiology Laboratory of Federal University of
São Paulo from February 2007 through November 2008 were prospec-
tively submitted to molecular analyses.

Published online ahead of print. Publication date available at www.cjasn.org.
Correspondence: Dr. Ita Pfeferman Heilberg, Rua Botucatu, 740, Vila Clementino,
São Paulo, SP, 04023-900, Brazil. Phone: 55-11-5904-1699; Fax: 55-11-5904-1684;
E-mail: ipheilberg@nefro.epm.br
Diagnostic Criteria and Patient Selection of E. coli UTIs
The selection of patients was based on a bacterial count ⱖ105
CFU/ml of E. coli in the urine culture irrespective of the results of the
urinalysis and a sufficiently detailed medical record available for a

Copyright © 2010 by the American Society of Nephrology ISSN: 1555-9041/507–1290

Clin J Am Soc Nephrol 5: 1290 –1297, 2010
retrospective analysis. A clinical diagnosis of PN or Cys, a prerequisite
for enrollment in the study presented here, was made in a total of 328
patients, from which 169 were renal transplant (Tx) recipients. Patients
presenting with prostatitis (n ⫽ 5), asymptomatic bacteriuria (n ⫽ 19),
neurogenic bladder (n ⫽ 6), and actinic Cys (n ⫽ 1) were excluded.
Further recurrent episodes of UTI occurring in the same patients were
also excluded from the analysis presented here (n ⫽ 37).
Written consent was obtained from all subjects, and the study was
approved by the local ethics committee of the Federal University of São
Paulo. Cys was clinically defined by the presence of dysuria, urinary
urgency, and frequency. Acute PN was defined by the presence of fever
(⬎38°C axillary) plus flank pain, with or without dysuria or urinary
frequency. In renal Tx patients, PN was defined by the presence of fever
and/or an increase of serum creatinine ⱖ20% over baseline values (21)
on the occasion of the positive urine culture. Other accompanying
symptoms or signs of PN included renal allograft tenderness, bactere-
mia, or a renal allograft biopsy specimen confirming bacterial PN. To
avoid possible confounding factors, patients with increased serum
creatinine due to acute cellular rejection, urinary tract obstruction, or
immunosuppressant-associated nephrotoxicity at the time of their UTI
were excluded. A decrease in serum creatinine or a negative urine
culture, available soon after antibiotic therapy, further confirmed the
presence of PN.
The parameters analyzed in the medical records were gender; age
over 60 years old; previous episodes of UTI; specific causes of ESRD
such as diabetes mellitus, nephrolithiasis, polycystic kidney disease
(PKD), and vesicoureteral reflux (VUR) to native kidneys. Information
about the type of kidney donor (living or deceased), the type of anas-
tomosis (Gregoir or Politano–Leadbetter), double J stent use, the time
posttransplantation, and the number of patients receiving tri-
methoprim/sulfamethoxazole (TMP/SMZ) prophylaxis and immuno-
suppression regimens were also sought. According to the routine of the
Renal Transplant Unit, immunosuppression induction was performed
in the cadaveric renal transplantation with basiliximab; thymoglobulin;
or more rarely with daclizumab, muromonab-CD3, or alemtuzumab.
Immunosuppression maintenance regimens consisted of (1) triple as-
sociations with calcineurin inhibitor (tacrolimus [Tac] or cyclosporine
[CsA]), prednisone (Pred), and mycophenolate agents (mycophenolate
mofetil [MMF], mycophenolate sodium [MPS], or azathioprine [Aza]);
(2) triple associations with Tac or CsA with Pred and sirolimus; and (3)
double associations with Tac or CsA with Pred. For the purpose of the
multivariate analysis, data were grouped as regimens, which were
mycophenolate-based, Aza-based, or the sum of all other associations.
Laboratory Analysis
Serum creatinine was determined (22) using a Hitachi 912 (Roche
Diagnostic System, Basel, Switzerland) isotope dilution mass spectrom-
etry traceable instrument. A freshly voided midstream urine sample
was used for the urinalysis and urine culture, and pyuria was defined
as a urinary leukocyte count ⬎104/ml. E. coli was isolated in selective
culture medium, and antimicrobial susceptibilities were determined by
a disk diffusion method (23).
Bacterial DNA Extraction and PCR Conditions
The whole volume of the urine specimen was harvested by centrif-
ugation for 10 minutes at 12,000 rpm in an Eppendorf centrifuge 5810R
(Eppendorf, Hamburg, Germany) for the bacterial genomic DNA ex-
traction (24). PCR with specific primers for bacterial 16S rRNA (25)
provided the validation of the DNA extraction. The presence of viru-
lence factors was assessed through PCR using separate specific primer
pairs for papC and aerobactin (26), papGII and papGIII (27), and M- and
Pyelonephritis in Renal Transplant Recipients 1291
G-fimbriae (28); under conditions described by Le Bouguenec et al. (29)
for papC and aerobactin; or under conditions described by Johnson et al.
(28) for papGII and papGIII and M- and G-fimbriae. All amplification
reactions were performed in iCycler BioRad Thermocycler (Bio-Rad
Laboratories), and products were electrophoresed on 2% agarose gels,
stained with ethidium bromide, and visualized with an ultraviolet
transilluminator and digital capture system EDAS 120 (Eastman Kodak
Company).
Statistical Analyses
Statistical analyses were conducted with SAS System for Windows,
version 8.02 (SAS Institute, Inc.). Categorical variables were compared
between groups using ␹2 or Fisher’s exact tests when appropriate.
Continuous variables were compared between groups using the Mann–
Whitney test. Multiple logistic regression analysis was used to deter-
mine host and E. coli virulence factors associated with PN. The level of
significance was defined as P ⬍ 0.05.
Results
The whole study group consisted of 328 patients, 169 Tx and
159 non-Tx patients, with no statistical differences regarding
age (44 versus 41 years). PN was diagnosed in 89 patients, most
of them (66.3%) Tx patients (n ⫽ 59), whereas Cys occurred in
239 patients, with 46% in Tx patients (n ⫽ 110). In the whole
sample, women represented most cases of Cys (89.1% versus
10.9%) and PN (76.4% versus 23.6%) compared with men. How-
ever, a statistical difference between PN and Cys in the whole
sample was observed among men (23.6% versus 10.9%, P ⬍
0.004).
The distribution of the signs, symptoms, and laboratory tests
is presented in Table 1. In the Tx patients, women had more Cys
(83.6%) and PN (69.5%) than men, but among men, there was a
higher frequency of PN than Cys, (30.5% versus 16.4%, P ⬍
0.03). Although Cys was more frequent among non-Tx female
than Tx female patients (93.8% versus 83.6%, P ⬍ 0.02), the
opposite was observed for PN, which was more prevalent
among male Tx than non-Tx patients (30.5% versus 10%, P ⬍
0.06). Among PN patients, the presence of fever was signifi-
cantly different between Tx and non-Tx patients (79.6% versus
100%) because this parameter was an inclusion criterion for the
latter group. Pyuria was observed more frequently among PN
isolates from Tx than from non-Tx patients (98.3% versus
66.7%). Within the group of Tx patients, the presence of pyuria
was also more often observed in PN than in Cys (98.3% versus
85.5%), as opposed to non-Tx patients, in whom pyuria was a
more common feature in Cys (87.6% versus 66.7%). Dysuria and
urinary frequency were symptoms more commonly observed
in Cys from non-Tx than from Tx patients (87.6% versus 64.5%
and 33.3% versus 3.6%, respectively).
The comparisons of host factors, E. coli virulence genes, and
antimicrobial resistance in all patients with Cys or PN are listed
in Table 2. The multivariate analysis showed significant asso-
ciations between the occurrence of PN and renal Tx (odds ratio
[OR] ⫽ 3.12, P ⬍ 0.001). Among bacterial factors, significant
associations between PN with the presence of papC (OR ⫽ 2.03,
P ⬍ 0.022), the lack of papGIII (OR ⫽ 4.88, P ⬍ 0.006), and lower
rates of resistance to nalidixic acid (OR ⫽ 2.90, P ⬍ 0.003) were
detected. Although papGII was more prevalent in PN than in
1292 Clinical Journal of the American Society of Nephrology Clin J Am Soc Nephrol 5: 1290 –1297, 2010

Table 1. Signs, symptoms, and laboratory tests

Tx Patients Non-Tx Patients P

PN, n 59 30
gender, n (%)
female 41 (69.5) 27 (90.0) 0.06
male 18 (30.5) 3 (10.0) 0.06
median age (min to max) 42 (18 to 73) 38 (19 to 61) –
flank pain – 30 (100.0) –
fever 47 (79.6) 30 (100.0) 0.007
pyuria 58 (98.3) 20 (66.7) 0.001
increase of serum creatinine 55 (93.2) – –
renal allograft tenderness 7 (11.8) – –
E. coli-positive hemoculture 6 (10.1) – –
renal allograft biopsy 2 (3.4) –
Cystitis, n 110 129
gender, n (%)
female 92 (83.6) 121 (93.8) 0.02
male 18 (16.4) 8 (6.2) 0.02
median age (min to max) 46 (18 to 69) 38 (18 to 89) –
dysuria 71 (64.5) 113 (87.6) 0.001
urinary frequency 4 (3.6) 43 (33.3) 0.001
suprapubic pain 7 (6.4) 15 (11.6) 0.1
pyuria 94 (85.5) 113 (87.6) 0.1
n (%), number (percentage) of patients.

Cys isolates (27.0% versus 16.7%, P ⬍ 0.043), the significance
was no longer observed in the multivariate analysis.
Comparisons of host and virulence factors in Tx patients with
PN and Cys are presented in Tables 3 and 4. The risk of
occurrence of PN was significantly higher among men (OR ⫽
2.35, P ⬍ 0.037) and for those no longer receiving TMP/SMZ
prophylaxis (OR ⫽ 2.73, P ⬍ 0.019). The percentage of PN and
Cys among patients receiving TMP/SMZ was significantly dif-
ferent (17.0% versus 30.9%). PN was associated with the lack of
papGIII (OR ⫽ 5.07, P ⬍ 0.041) and with lower rates of resis-
tance to pipemidic acid (OR ⫽ 2.57, P ⬍ 0.014). There were
statistical differences between PN and Cys isolates with respect
to papGII (23.7% versus 11.0%, P ⬍ 0.03) and for resistance to
nalidixic acid (20.3% versus 37.3%, P ⬍ 0.03). However, such
differences were no longer observed in the multivariate analy-
sis. Nitrofurantoin resistance was not identified in any isolated
strain in the study presented here.
When we categorized Tx patients according to the time after
transplantation (data not shown in the table), we did not iden-
tify a significant increase in the occurrence of PN per each
6-month period (OR ⫽ 1.03, 95% confidence interval 0.990 to
1.077, P ⬍ 0.135).
There were no statistical differences between the percentage
of patients with Cys or PN regarding immunosuppressive in-
duction with basiliximab (20.0% versus 18.6%), daclizumab
(1.8% versus 5.1%), alemtuzumab (1.0% versus 0.0%), mu-
romonab-CD3 (1.0% versus 0.0%) and thymoglobulin (7.2% ver-
sus 6.8%). The various maintenance immunosuppressive regi-
mens were also not statistically different with respect to Cys or
PN isolates from patients receiving Tac/Pred/MMF (5.5% ver-
sus 3.4%), Tac/Pred/Aza (19.1% versus 16.9%), CsA/Pred/Aza
(14.5% versus 25.4%), CsA/Pred/MMF (3.6% versus 5.1%),
CsA/Pred (6.3% versus 3.4%), Tac/Pred/MPS (20.1% versus
16.9%), Tac/Pred (3.6% versus 1.7%), CsA/Pred/MPS (10% ver-
sus 10.2%), or Siro/Pred/Tac (6.4% versus 1.7%).
Discussion
The severity of a UTI is determined by the virulence of the
infecting strain modulated by the innate immune response of
the host (30). Although there are several studies assessing E. coli
virulence genes in upper UTI (5,11–13), only one of them has
been conducted in renal Tx recipients (21). We aimed to eval-
uate host and bacterial virulence factors mostly associated with
PN by E. coli in Tx patients.
In the study presented here, renal Tx was associated with a
3-fold increase in the risk of developing PN (OR ⫽ 3.12). Such
a finding raises the hypothesis that immunosuppression, neo
ureterovesical implantation, shorter ureter, manipulated blad-
ders, and other conditions inherent in renal Tx may contribute
to a higher risk of PN. However, we did not find statistical
differences among different immunosuppression schemes,
namely triple-drug regimens using mycophenolate or Aza and
others (sirolimus-based or double-drug regimens) with respect
to the occurrence of PN, as also observed by Pellé et al. (6).
Notwithstanding, Kamath et al. (31) did find an association
with the use of Mycophelonate and PN in Tx patients, but the
number of patients was smaller than ours.
Some studies reported a greater prevalence of women (6,32),
Clin J Am Soc Nephrol 5: 1290 –1297, 2010 Pyelonephritis in Renal Transplant Recipients 1293

Table 2. The distribution of host and virulence factors of E. coli among all patients with Cys and PN
Univariate Analysis Multivariate Analysis
Cys PN
(n ⫽ 239) (n ⫽ 89)
OR 95% CI P OR 95% CI P

Host factors
age ⱖ60 years 40 (16.7) 12 (13.5) 0.78 0.39 to 1.56 0.47
male gender 26 (10.9) 21 (23.6) 2.53 1.34 to 4.78 0.004
previous UTI 104 (43.5) 44 (49.4) 1.27 0.78 to 2.07 0.34
diabetes mellitus 17 (7.1) 10 (11.2) 1.65 0.73 to 3.76 0.23
nephrolithiasis 31 (12.9) 10 (11.2) 0.85 0.40 to 1.81 0.67
PKD 10 (4.2) 2 (2.3) 0.53 0.11 to 2.45 0.41
renal Tx 110 (46.0) 59 (66.3) 2.31 1.39 to 3.83 0.001 3.12 1.80 to 5.39 0.001
Urovirulence genes of E. coli
papC 55 (23.1) 28 (31.5) 1.53 0.89 to 2.62 0.124 2.03 1.11 to 3.72 0.022
papGII 40 (16.7) 24 (27.0) 1.82 1.02 to 3.24 0.043
papGIII 32 (13.4) 4 (4.5) 3.28 1.13 to 9.57 0.029 4.88 1.57 to 15.12 0.006
M-fimbriae 10 (4.2) 3 (3.4) 0.80 0.22 to 2.97 0.74
G-fimbriae 3 (1.3) 0 0.38 0.02 to 7.38 0.29
aerobactin 59 (24.8) 25 (28.1) 1.19 0.69 to 2.05 0.54
Antibiotic resistance
TMP/SMZ 97 (40.6) 41 (46.1) 1.25 0.77 to 2.04 0.37
nalidixic acid 62 (26.0) 12 (13.5) 2.25 1.15 to 4.41 0.018 2.90 1.42 to 5.93 0.003
pipemidic acid 64 (26.8) 14 (15.7) 1.90 1.01 to 3.61 0.049
ciprofloxacin 55 (23.1) 12 (13.5) 0.52 0.26 to 1.02 0.06
norfloxacin 55 (23.1) 12 (13.5) 0.52 0.26 to 1.02 0.06
ampicilin 119 (49.8) 47 (52.8) 1.13 0.69 to 1.84 0.63
cefalotin 60 (25.1) 26 (29.2) 1.23 0.72 to 2.12 0.45
ceftriaxone 5 (2.1) 1 (1.1) 0.53 0.06 to 4.62 0.56
gentamicin 17 (7.1) 4 (4.5) 0.62 0.20 to 1.88 0.39
nitrofurantoin 0 0 – – –
n (%), number (percentage) of patients. CI, confidence interval.

whereas others did not find any sex-related differences in the
frequency of posttransplantation PN (31). Nevertheless, these
studies (31,32) differ from ours because they did not compare
PN with Cys, but rather patients who developed PN versus
those who never did. In the study presented here, although any
UTI event by E. coli was statistically more frequent in women
than in men, when we compared PN with Cys patients, it
became evident that PN in Tx patients occurred more often in
men, and the risk of PN was 2-fold higher in men. Although
other investigators also observed higher rates of PN among
men (11), the reasons for the predilection of male gender in the
series of Tx patients presented here remain unclear. Our find-
ings could not be ascribed solely to older age and consequently
to prostatism because the Cys and PN groups were young and
comparable with respect to age (49.3 ⫾ 13.1 years versus 46.5 ⫾
14.8 years, respectively NS). In a recent retrospective analysis
based on data from the U.S. Renal Data System, Hurst et al. (33),
have shown that benign prostatic hyperplasia (BPH) is very
common in men after renal Tx and is independently associated
with UTI. Age was independently associated with BPH in their
reports, but whether BPH was causing more upper (PN) than
lower (Cys) UTI could not be further specified (33). One potential
limitation of this study is that it was not possible to entirely rule
out the effect of BPH or prostatism in the series presented here
because of its retrospective design. Finally, according to Sadeghi et
al. (34), male renal Tx recipients with UTI might present a stronger
inflammatory cytokine response than female patients who block
inflammatory responses by producing soluble IL-1 receptor an-
tagonist, possibly because of continuous stimulation of the blad-
der by insignificant bacteriuria. Whether this stronger response
may be linked to the invasion of the upper urinary tract, especially
in Tx patients, remains to be determined.
Specific causes of ESRD (e.g., diabetes mellitus, autosomal
dominant PKD, nephrolithiasis, or VUR) were not associated
with an increased risk of PN in the study presented here, in
agreement with other reports (6,31). According to Rice et al.
(21), diabetes mellitus was even more associated with Cys rather
than with PN among Tx patients. It is possible that the lack of
association between PN with autosomal dominant PKD, nephro-
lithiasis, and VUR with native kidneys was because of the small
number of these diseases in the sample presented here.
We did not find any association between PN and the use of
a double J stent, in accordance with the study of Kumar et al.
(35). On the other hand, Kamath et al. (31) observed a 4-fold
increase in the risk of PN in Tx patients with ureteric stents.
1294 Clinical Journal of the American Society of Nephrology Clin J Am Soc Nephrol 5: 1290 –1297, 2010

Table 3. The distribution of host factors among Tx patients with Cys and PN
Univariate Analysis Multivariate Analysis
Cys PN
(n ⫽ 110) (n ⫽ 59)
OR 95% CI P OR 95% CI P

Host factors
age ⱖ60 years 19 (17.3) 9 (15.3) 0.86 0.36 to 2.05 0.74
male gender 18 (16.4) 18 (30.5) 2.24 1.06 to 4.75 0.04 2.35 1.06 to 5.22 0.037
previous UTI by E. coli 60 (54.5) 33 (56.0) 1.06 0.56 to 2.00 0.86
diabetes mellitus 15 (13.6) 10 (17.0) 1.29 0.54 to 3.09 0.56
nephrolithiasis 3 (2.7) 1 (1.7) 0.62 0.06 to 6.05 0.68
PKD 9 (8.2) 2 (3.4) 0.39 0.08 to 1.89 0.24
VUR 2 (1.8) 1 (1.7) 0.93 0.08 to 10.49 0.95
deceased donor (versus living) 53 (48.2) 29 (49.2) 1.04 0.55 to 1.96 0.90
Gregoir versus Politano 75 (68.2) 40 (67.8) 1.02 0.52 to 2.00 0.96
anastomosis
TMP/SMZ prophylaxis 34 (30.9) 10 (17.0) 2.19 0.99 to 4.84 0.05 2.73 1.18 to 6.29 0.019
use of double J stent 23 (20.9) 19 (32.2) 1.80 0.88 to 3.67 0.11
Immunosuppression regimen
mycophenolate-baseda 43 (39.1) 21 (35.6) 1.00 – –
Aza-based 37 (33.6) 25 (42.4) 1.38 0.67 to 2.87 0.38
others 30 (27.3) 13 (22.0) 0.89 0.39 to 2.04 0.78
n (%), number (percentage) of patients.
a
Reference.

Table 4. The distribution of E. coli virulence factors among Tx patients with Cys and PN
Univariate Analysis Multivariate Analysis
Cys PN
(n ⫽ 110) (n ⫽ 59)
OR 95% CI P OR 95% CI P

Urovirulence genes of E. coli

papC 18 (16.5) 14 (23.7) 1.59 0.73 to 3.48 0.25
papGII 12 (11.0) 14 (23.7) 2.54 1.09 to 5.93 0.03
papGIII 15 (13.6) 2 (3.4) 4.50 0.99 to 20.38 0.05 5.07 1.07 to 24.13 0.041
M-fimbriae 5 (4.6) 1 (1.7) 0.36 0.04 to 3.17 0.36
G-fimbriae 2 (1.8) 0 0.36 0.02 to 7.72 0.30
aerobactin 24 (21.8) 14 (23.7) 1.12 0.53 to 2.36 0.78
Antibiotic resistance
TMP/SMZ 57 (51.8) 30 (50.9) 0.96 0.51 to 1.81 0.90
nalidixic acid 41 (37.3) 12 (20.3) 2.33 1.11 to 4.89 0.03
pipemidic acid 46 (41.8) 13 (22.0) 2.54 1.23 to 5.24 0.01 2.57 1.21 to 5.46 0.014
ciprofloxacin 37 (33.6) 12 (20.3) 0.50 0.24 to 1.05 0.07
norfloxacin 37 (33.6) 12 (20.3) 0.50 0.24 to 1.05 0.07
ampicilin 64 (58.2) 33 (55.9) 0.91 0.48 to 1.73 0.78
cefalotin 39 (35.4) 21 (35.6) 1.01 0.52 to 1.95 0.98
ceftriaxone 2 (1.8) 1 (1.7) 0.93 0.08 to 10.49 0.95
gentamicin 11 (10.0) 4 (6.8) 0.66 0.20 to 2.15 0.48
nitrofurantoin 0 0 – –
n (%), number (percentage) of patients.

These findings might have been accounted for by an earlier
removal of stents in our service (36) compared with others (31).
Kidneys from deceased donors and Gregoir-type of anasto-
mosis did not show higher rates of PN in the sample presented
here, in agreement with other studies (6,31,32).
In this study, the percentage of patients receiving TMP/SMZ
prophylaxis against Pneumocystis carinii was significantly lower
in the PN than in the Cys group, and the multivariate analysis
showed a risk almost 3-fold lower of developing PN when on
TMP/SMZ (OR ⫽ 2.73), despite high TMP/SMZ resistance
Clin J Am Soc Nephrol 5: 1290 –1297, 2010
rates (approximately 50% in both groups). A separate analysis
of resistance to TMP/SMZ only on patients who developed
either PN or Cys receiving TMP/SMZ prophylaxis showed a
nonsignificant trend for higher rates of resistance in PN (8 of 10
[80%]) versus Cys (21 of 34 [62%]). Other reports also observed
decreased rates of UTI associated with TMP/SMZ prophylaxis
(37,38) but not particularly with PN.
There is no conclusive evidence whether or not the presence
of virulence factors is correlated with differences in suscepti-
bility to antimicrobials. Although some investigators suggested
that virulence genes increased antibiotic resistance of previ-
ously resistant strains (16), others observed that quinolone-
resistant E. coli strains were more prone to induce Cys rather
than PN (17,18,20) because of decreased renal invasive capacity
concomitantly acquired by the mutation. Our findings, in
agreement with those reports, showed a lower proportion of E.
coli resistance to first-generation quinolones in PN isolates: the
risk of resistance in PN isolates to nalidixic acid was reduced in
the whole sample (OR ⫽ 2.90) and to pipemidic acid in the Tx
group (OR ⫽ 2.57). Resistance to ciprofloxacin or norfloxacin
was also less frequent in PN isolates, almost achieving statisti-
cal significance. We did not observe a single case of fluorquin-
olone resistance among the PN isolates of non-Tx patients. We
hypothesize that the slightly higher resistance to fluorquinolo-
nes in PN isolates from Tx patients compared with the non-Tx
patients might have been consequent to their more frequent use
in this population, selecting resistant strains.
The reported prevalence of papC-positive E. coli strains iso-
lated in patients with UTIs is highly variable—10% to 77%
(5,13,28,39 – 41), and only two studies have found a higher
prevalence of papC-positive E. coli in PN versus Cys isolates
(50% versus 10% (13) and 76% versus 35% (5)). These studies did
not include patients with renal Tx. The current prevalence of
papC in PN isolates from Tx patients was not significantly
different from Cys isolates. Although the multivariate analysis
suggested risk for papC in PN isolates in the series presented
here (OR ⫽ 2.03), it was not an independent risk given that the
univariate analysis was NS.
Previous studies have demonstrated that among the three
classes of papG genes, only papGII is associated with PN
(5,11,12,15). In the study presented here, the univariate analysis
showed papGII to be more often associated with PN than with
Cys in the whole sample and also in Tx patients. However, it
did not represent an independent risk factor for PN. Our prev-
alence of 27% of papGII in PN is not high if compared with other
studies that reported rates of 54% to 93% in the non-Tx popu-
lation (5,11,12,15). In Tx patients, Rice et al. (21) found signifi-
cant differences regarding the papGII prevalence between PN
and lower UTIs— 47% versus 18%. Nevertheless, in experimen-
tal models, Mobley et al. (42) have shown that adherence me-
diated by the P-fimbrial adhesin played only a subtle role in the
development of PN. Additionally, it has been observed that
although PapGII enhanced the establishment of kidney infec-
tions by E. coli in mice, infections did not persist because of the
immune response (43). According to Tseng et al. (11), P-fimbria
virulence factors have been suggested to be less common under
immunosuppression, although the exact distribution of papGII
Pyelonephritis in Renal Transplant Recipients 1295
among isolates of PN from immunosuppressed patients was
not specified (11). Some investigators observed a lower pre-
dominance of papGII in E. coli isolated from UTI patients with
urinary abnormalities, either in children (44,45) or in adults
(46). Although patients with neurogenic bladder were excluded
from the sample presented here, UTI occurring in a trans-
planted patient is already considered as a complicated one (47)
because of the heterotopic position of the graft and the shorter
ureteral length. Finally, studies that observed a high prevalence
of papGII in PN could have been biased by the exclusion of
quinolone-resistant strains (5) because the latter would possibly
possess fewer virulence factors (5,13).
Several studies have demonstrated that PapGIII is mostly
identified in acute Cys strains (48 –50) because Forsmann anti-
gen, the host cell receptor, is rare in renal cells. This is in
agreement with our observation that the papGIII prevalence
was higher in Cys versus PN in all patients including the Tx
ones. Thus, the lack of papGIII in E. coli strains was an inde-
pendent factor associated with PN in all patients (OR ⫽ 4.88)
and Tx patients (OR ⫽ 5.07). On the other hand, some studies
did not find any association between papGIII and PN in non-Tx
(5,11,13,15) or Tx patients (21), with the prevalence ranging
from 4% to 35%.
The aerobactin prevalence in E. coli strains is also highly
variable in the literature, from 26% to 85% (5,11,13,15,28,39,40).
In this study, the prevalence of aerobactin was up to 28% but
not significantly different between the PN and Cys isolates,
coinciding with some reports (11,15) but not with others (5,13).
There are few studies about the association of M- and G-
fimbriae with UTIs (5,28,41) and none in a Tx setting. The
current prevalence of these fimbriae was very low (up to 4.2%,
in agreement with other authors (28,41)) and did not differen-
tiate PN from Cys.
In conclusion, the data presented here suggest that renal Tx
increased the risk for PN, and the male sex represented a host
factor independently associated with risk, whereas the prophy-
laxis with TMP/SMZ was protective. Although papGII was
more prevalent in PN than in Cys, it was not independently
associated with PN in Tx, whereas the lack of papGIII was
considered as an independent risk factor for PN. Immunosup-
pression, abnormal urinary tract, and resistance to quinolones
are some features that might have explained the lower preva-
lence of papGII in PN, suggesting that bacteria presenting with
fewer virulence genes may invade the upper urinary tract in Tx
patients.
Another limitation of this and other studies is that only the
prevalence rather than expression of virulence factor genes
have been evaluated. Studies examining the expression of such
virulence factors in lower and upper UTIs in renal Tx recipients
must be conducted to further confirm such findings.
Acknowledgments
This research was supported by grants from the Conselho Nacional
de Desenvolvimento Científico e Tecnológico (CNPq) and Fundação
Oswaldo Ramos. Portions of this study were presented at the 41st
Annual Meeting of the American Society of Nephrology, Philadelphia,
Pennsylvania, November 6 to 9, 2008, and at the 8th World Congress of
1296 Clinical Journal of the American Society of Nephrology
Nephrology, Milan, Italy, May 22 to 26, 2009. We express our thanks to
Silvia Regina Moreira and Antonia Maria Machado, M.D. for technical
assistance, and to Samirah Abreu Gomes, Ph.D., M.D. for fruitful dis-
cussions.
Disclosures
None.
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