Graft intolerance syndrome in children with failed kidney allografts—clinical presentation, treatment options and outcome

Background. Failed renal allografts left in situ may cause inflammation presenting as graft intolerance syndrome (GIS). There are no sufficient data regarding clinical course and treatment options of GIS in paediatric patients. Methods. A retrospective study of all children with failed renal allografts treated in Schneider's Children Medical Center of Israel during a 10-year period was conducted. Diagnosis of GIS was based on clinical criteria and persistence of renal perfusion according to radio-isotopic scan. Results. Twenty children with failed renal allografts were studied. The mean age at transplantation was 10.3 ± 4.9 years. The mean graft survival was 2.9 ± 2.5 years. Two grafts were removed immediately due to vascular complications. Of the 18 patients with transplants remaining in situ, 11 (61%) developed GIS within 2.7 ± 2.1 months after restarting dialysis. GIS manifestations included fever (91%), local tenderness (82%), hypertension (73%), abdominal pain (64%), macroscopic haematuria (27%), pulmonary congestion (27%) and enlargement of the graft (18%). Laboratory findings included anaemia, hypoalbuminaemia and elevated ESR and CRP. Three patients were successfully treated with indomethacin and/or prednisone. In one patient the graft was surgically removed due to suspected post-transplantation lymphoproliferative disorder. Seven patients underwent percutaneous embolization of the graft, and in six patients a complete resolution of symptoms occurred within 32.2 ± 45 days. Complications included abscess and retinal artery thrombosis. Six patients were successfully re-transplanted, three are still on haemodialysis and two died of causes unrelated to GIS. Conclusions. GIS may be common among children with failed renal allografts. Percutaneous embolization of the graft seems effective and safe. Further studies are needed to evaluate late outcome of paediatric patients with GIS.