Abstract: SA-PO1177
From Delayed Kidney Graft Function and Pyelonephritis to Graft Intolerance Syndrome
Session Information
- Transplantation: Clinical - Complications, Pediatrics, and Multi-Organ Considerations
October 24, 2026 | Location: Exhibit Hall A, Convention Center
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 2002 Transplantation: Clinical
Authors
- Frost, Livia Ann, Baylor College of Medicine, Houston, Texas, United States
- Jimenez, Yajaira Sofia, Baylor College of Medicine, Houston, Texas, United States
- Aggarwal, Nidhi, Baylor College of Medicine, Houston, Texas, United States
Introduction
Graft Intolerance Syndrome (GIS) causes debilitating systemic symptoms in failed renal allografts and is hard to diagnose as it mimics infection. We present a case of GIS initially obscured by delayed graft function (DGF) and recurrent transplant pyelonephritis. This report reinforces that nephrectomy remains definitive for GIS when infection is in the differential.
Case Description
A 58-year-old female with ESKD secondary to FSGS underwent a deceased donor kidney transplant (DDKT). Her post-transplant course was complicated by DGF. Transplant biopsy revealed acute pyelonephritis, requiring prolonged antibiotics. Due to recurrent infections and graft failure, dialysis was restarted and immunosuppression was weaned off.
Six month later, she presented with two months of failure to thrive, 20-pound weight loss, fevers, hematuria, and persistent RLQ pain. She was febrile, hypotensive, and had severe, persistent erythropoietin-resistant anemia and leukocytosis. CT showed an enlarged, inflamed transplanted kidney. Her symptoms persisted despite broad-spectrum antibiotics for presumed recurrent pyelonephritis while blood and urine cultures remained negative; a trial of steroids for suspected GIS also failed to improve her symptoms.
Given the refractory course in a failed, non-immunosuppressed graft, the diagnosis was revised to GIS and she underwent a successful transplant nephrectomy. Pathology confirmed the graft’s final common pathway: end-stage renal disease with extensive necrosis, acute on chronic pyelonephritis, and features of rejection. Her symptoms resolved postoperatively.
Discussion
The patient’s history of DGF and recurrent pyelonephritis initially steered management toward infection, delaying GIS diagnosis. A steroid trial failed to provide sustained improvement, consistent with reports that steroids may be only a temporary bridge. Symptom resolution following nephrectomy reinforces that removal of the failed allograft is curative when GIS is suspected and infection reasonably excluded. This case illustrates the diagnostic triad of GIS: refractory systemic illness, failed graft off immunosuppression, and exclusion of infection. Steroids may be tried but are often a bridge to definitive nephrectomy.