Urinary Tract Infections in Kidney Transplant Recipients: A Narrative Review

Urinary tract infections (UTIs) are the most frequent infectious complication after kidney transplantation and are associated with rehospitalizations, impaired allograft function, and reduced graft and recipient survival. Their clinical relevance is amplified by chronic kidney disease (CKD)-related immune dysfunction and the rising burden of antimicrobial resistance METHODS: We provide a focused narrative review of classification, pathophysiology, risk factors, and evidence-based management and prevention strategies for UTIs in kidney transplant recipients, with emphasis on antimicrobial stewardship and non-antibiotic adjuncts RESULTS: Post-transplant UTI risk is highest in the early months and is driven by intensive immunosuppression, perioperative urological devices (bladder catheter, ureteral stents), delayed graft function/ischemia-reperfusion injury, and urodynamic abnormalities (post-void residual, vesicoureteral reflux). Female sex and pregnancy further increase susceptibility. Urine cultures must be interpreted in the context of time from transplantation and symptoms. Systematic treatment of asymptomatic bacteriuria is not beneficial and may increase antibiotic exposure and selection of multidrug-resistant organisms. Conversely, symptomatic, complicated, and recurrent UTIs warrant prompt empiric therapy followed by rapid de-escalation based on culture and susceptibility results. Preventive strategies targeting adhesion and colonization include adequate hydration, standardized cranberry preparations with therapeutically effective proanthocyanidin dosing, methenamine hippurate in selected patients, and topical vaginal estrogen in peri-/postmenopausal women; evidence for D-mannose and probiotics remains inconsistent. Emerging mechanistic insights highlight uromodulin as a key anti-adhesive and neutrophil (NET)-modulating defense factor, while SGLT2 inhibitors may modify tubular biomarkers; a UTI episode should not automatically prompt treatment discontinuation CONCLUSIONS: UTI management after kidney transplantation should adopt an integrated, multimodal approach combining stewardship-driven antibiotic use with tailored non-antibiotic preventive interventions to reduce recurrences, curb resistance, and preserve long-term allograft longevity.