Ultrasound examination of failed renal transplant in patients with graft intolerance syndrome. Case series

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Background. The number of kidney transplantations is increasing worldwide. Therefore, the number of patients with a failed renal graft (RG), returning to dialysis is increasing too. The most common indication for transplantectomy (TE) in patients with late dysfunction is graft intolerance syndrome (GIS). GIS is a reactivation of rejection processes in a failed RG amidst the significant reduction or cessation of immunosuppressive therapy (IST). The diagnosis of GIS is based on clinical and laboratory criteria, including fever, flu-like condition, local pain, tumescence in the graft area, hematuria, anemia, and increased markers of systemic inflammatory response in the absence of a concomitant infectious process. The question of Doppler ultrasound characteristics of GIS remains open. Materials and Methods. A clinical case series of 7 patients (age 25-51 y) with signs and symptoms of GIS is presented (2019-2022 y). At the time of inclusion in the study, all patients received maintenance hemodialysis from 6 months to 3 years. The functioning time of RG was from 9 months to 10 years. Two patients underwent repeated kidney transplantation. All patients underwent a comprehensive ultrasound examination including a Doppler ultrasound evaluation of RG. The special features of TE and subsequent pathohistological examination were studied. Results. All patients demonstrated typical clinical and laboratory signs of GIS (Hb from 74 to 116 g/L, (Me (IQR) 94 [81; 102]), CRP from 12 to 84 mg/L, (Me (IQR) 43 [18; 72]). Most patients had a history of humoral rejection and skipped IST. According to Grayscale examination in all cases thickening pseudocapsule, graft contour unevenness and blurriness of renal pyramids were detected. The increased size of the renal graft was found in 6 patients. Color Doppler mapping demonstrated active intraparenchymal blood flow with disturbed angioarchitectonics and perirenal collaterals. Power Doppler provided a wide variety of spectrums, including collateral and stenotic at different vascular levels. TE was performed in all cases. 5 patients underwent laparoscopic surgery (3 - subcapsular extraction). Median blood loss was 300 mL (IQR) [150; 400]. 2 cases of opened TE complicated by graft bed hematomas and one case complicated by surgical infection. Histopathological examination of removed grafts revealed the signs of acute and chronic vascular rejection. In addition, there was marked narrowing of the arteries of medium and small caliber and signs of severe parenchymal ischemia. Conclusion. All patients with failed RG should be given comprehensive US examination, including Doppler. GIS with active vascular component has characteristic Doppler signs. The presence of perirenal collaterals, active blood flow in failed RG, and fibrous pseudocapsule create additional challenges for TE and require a personalized approach to the choice of surgical tactics.

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