The Case | Hematuria and hypercalcemia in a kidney transplant recipient.

A 25-year-old woman presented with dysuria and intermittent gross hematuria for 2 weeks. She underwent a kidney transplantation 2 years earlier because of end-stage kidney disease of unknown cause. She received basiliximab as induction therapy, followed by maintenance immunosuppression with mycophenolate mofetil 1,000 mg/day, tacrolimus with a target trough level of approximately 5 ng/ml, and prednisolone. Allograft function had been stable, with a serum creatinine of 1.4 mg/dl over the past year. Two weeks before the presentation, she developed dysuria, and the urine color was reddish yellow without clot. She was prescribed oral norfloxacin to treat presumed urinary tract infection but without improvement of symptoms. On examination, her body temperature was 38.6 °C. Laboratory tests showed serum creatinine of 5.1 mg/dl, calcium of 16.1 mg/dl, phosphate of 4.0 mg/dl, intact parathyroid hormone of 4.5 pg/ml, and no monoclonal gammopathy. Urinalysis was notable for 5 to 10 red blood cells per high-power field without proteinuria. Kidney allograft ultrasonography showed diffuse thickening of the proximal ureter, which was compatible with infection or inflammatory process (Figure 1, arrowhead).