Late-onset Antibody-mediated Rejection in a Failed Allograft Masquerading as Pyrexia with Hematuria

A 35-year-old male failed allograft renal transplant recipient with a significant past history of delayed graft function, deceased donor transplant, and previous episodes of antibody-mediated rejection (ABMR) presented with a history of pyrexia and gross hematuria 6 months after hemodialysis reinitiation. Laboratory examination revealed anemia, and urine showed macroscopic hematuria with trace proteinuria. All cultures were sterile, and evaluation for opportunistic pathogens was noncontributory. Due to persistent hematuria and high-grade fever, he underwent graft nephrectomy, which revealed changes of ABMR with renal-limited thrombotic microangiopathy. This case report explores the challenges of posttransplant hematuria and immunosuppression protocols in a failed allograft renal transplant recipient.