Emphysematous Pyelonephritis After Embolization of a Nonfunctioning Kidney Graft

Emphysematous pyelonephritis (EPN) is a rare but severe infection with a high mortality rate characterised by gas formation within the renal parenchyma. Although primarily affecting native kidneys, EPN may exceptionally develop in nonfunctioning renal allografts. We report two cases of EPN occurring after therapeutic embolization of nonfunctioning kidney grafts because of graft intolerance syndrome (GIS). The first case involved a 50-year-old KT woman with a history of post-transplant diabetes and recurrent urinary tract infections, who developed EPN 3 months after embolization. Despite initial improvement with antibiotics, her condition worsened, requiring urgent transplant nephrectomy, which led to full recovery. The second case involved a 54-year-old woman with two failed KT and a previous nephrectomy due to infectious complications. Failure of the third graft due to acute rejection and GIS required embolization. She presented with septic shock 1 month after embolization. Due to clinical deterioration, urgent transplant nephrectomy was performed, resulting in a favourable outcome. These cases underscore that EPN in nonfunctioning renal allografts is an extremely rare clinical entity but should be considered in the differential diagnosis of sepsis following embolization. In severe cases, prompt surgical intervention with transplant nephrectomy, alongside broad-spectrum antibiotics and intensive supportive care, may be necessary for optimal management.