ICU Decoded › Library › Ward Pathways › Miscellaneous › The Transplant Patient with FeverThe Transplant Patient with FeverEmergency
Miscellaneous · Ward Pathways · Locked — free with a referral
By Dr Javed Akhtar · Last reviewed 21 October 2026
Presentation Renal transplant 4 months ago on tacrolimus, mycophenolate and prednisolone; fever 38.8 °C, dry cough, creatinine up 40%
Red flags Hypoxaemia with a normal chest radiograph — think PJP Headache or confusion — think Cryptococcus, Listeria, Nocardia Rapidly rising creatinine in a renal graft Neutropenia on valganciclovir or mycophenolate Differential diagnosis Bacterial sepsis CMV disease Pneumocystis pneumonia Invasive fungal infection Tuberculosis Acute rejection Drug fever Post-transplant lymphoproliferative disease When to admit, call ICU or discharge Admit: Any fever in a transplant recipientICU: Septic shock, hypoxaemia, graft dysfunction, or suspected CNS infectionKey points Time since transplant frames the differential: <1 month surgical, 1–6 months opportunists, >6 months community plus late opportunists. Hold the antimetabolite, keep the calcineurin inhibitor with levels, cover steroids in shock. Tissue early — yield falls once antimicrobials start. Never Stop all immunosuppression without the transplant team Start an azole, macrolide or rifampicin without planning the calcineurin-inhibitor dose and level Assume a normal WCC excludes infection Give live vaccines Common mistakes Stopping all immunosuppression and precipitating rejection Starting an azole without adjusting tacrolimus Attributing hypoxaemia to fluid overload and missing PJP Assuming a normal white count excludes infection Disposition and follow-up Every decision is taken with the transplant centre; graft function, drug levels and the infection plan are reviewed together, daily.
Locked ABCDE first moves The step-by-step decision sequence Order set Monitoring timeline and escalation triggers Treatment doses and preparation Discharge package Open the full pathway in Ward Pathways
Free with a referral from any ICU Decoded member, or by applying with your medical registration. How access works .
← Rheumatological Emergencies · Thyroid Storm and Myxoedema Coma →
More Miscellaneous pathways
Part of Miscellaneous in Ward Pathways — open the interactive version .