Abstract
Graft intolerance syndrome (GIS) is a well-recognized complication after kidney allograft failure, characterized by fever, graft pain, and systemic inflammation. Management options include continued immunosuppression, graft nephrectomy, and renal artery embolization, each associated with specific risks. We report a case of GIS successfully treated with percutaneous renal allograft artery embolization using carbon dioxide angiography in a patient with iodinated contrast allergy. A 66-year-old woman with autosomal dominant polycystic kidney disease underwent living-donor kidney transplantation and later developed chronic allograft dysfunction, eventually resuming hemodialysis. Following immunosuppression tapering, she presented with recurrent fever and pain over the renal allograft. Despite broad-spectrum antibiotic therapy, her symptoms persisted and imaging showed no abscess formation. Repeated blood cultures were negative. Allograft biopsy revealed extensive tissue necrosis with interstitial inflammation and vascular thrombosis. Multiple donor-specific anti-human leukocyte antigen antibodies with high mean fluorescence intensity were detected, suggesting ongoing alloimmune sensitization. Based on the clinical course and investigations, GIS was diagnosed. Given the high surgical risk and contrast allergy, percutaneous embolization of the renal allograft artery was performed using a combination of carbon dioxide angiography and CT guidance. Clinical symptoms improved promptly after the procedure, allowing discontinuation of calcineurin inhibitor therapy and steroid tapering, with no recurrence during follow-up. This case highlights carbon dioxide contrast angiography- and computed tomography-guided renal artery embolization as a safe and effective minimally invasive treatment option for GIS, particularly in patients unsuitable for iodinated contrast media or surgical nephrectomy.