Background: In patients after a renal transplant, life-long immunosuppression is a part of absolutely required treatment to prevent acute graft rejection. Faced with severe infection or impending sepsis the immunosuppression further complicates treatment, especially in case of sepsis-induced secondary immunosuppression.
Case Report: We present a case of a 57-year old female (with h/o autosomal
dominant polycystic kidney disease, hypertension, secondary diabetes mellitus, end-stage chronic renal disease, post bilateral nephrectomy) who was admitted to ICU 2 months after a renal transplant with severe respiratory failure secondary to pneumonia. She subsequently developed septic shock with neutropenia. Routine microbiological screening showed E.coli ESBL (+) growth, patient was treated according to microbiology sensitivity. The immunosuppressive agents (tacrolimus, corticosteroids) were continued throughout the course of treatment to prevent acute graft rejection, mycophenolate mofetil was discontinued on admission to ICU. Despite multimodal approach (including HVCVVH, drotrecogin alfa infusion) patient died on the 4th day after admission (cardiac arrest, asystole).
Conclusions: Net state of immunosuppression is achieved as a balance between exposure to infectious agents (hospital or community sources) and overall immunosuppression level. This case raises one important issue. A question of the timing and extent of immunosuppression withdrawal: at the
diagnosis of severe infection, when the diagnosis of sepsis is made or when
neutropenia occurs in the course of sepsis?

Keywords: Immunosuppression, Kidney Transplantation