Salvage Nephrectomy for Postembolization Syndrome: A Case Report

Introduction: Graft intolerance syndrome (GIS) occurs in up to 50% of patients with a failed graft in the first year. Embolization and nephrectomy are two available options for management of GIS. Case Description: We present the case of a 42- year-old man with a history of end-stage kidney disease (ESKD) secondary to type 1 diabetes mellitus (DM1), status post simultaneous pancreas and kidney transplantation (SPK) around 5 years ago. His pancreas failed around a year ago and later his kidney failed a few months ago. Prednisone was tapered while tacrolimus was kept, and he developed abdominal pain, low grade fever, malaise, fatigue and worsening anemia for which he was seen in the emergency room multiple times before he was admitted. CT scan revealed and inflammation of his transplanted kidney. He was diagnosed with GIS, received high dose steroids with temporary improvement, then needed embolization as he was deemed a high risk for surgery. He had an initial improvement in his symptoms then he developed a refractory pain over the kidney graft with malaise and fatigue. Labs showed leukocytosis, elevated CRP and pro-calcitonin, negative chest x-ray and a normal UA. Nephrectomy was performed and an edematous kidney was removed. His pancreas was never an issue. He was later discharged and remains stable on home hemodialysis. Discussion: GIS presents a diagnostic challenge and can be refractory to high dose steroids. Embolization offers a quick solution especially in poor surgical candidates, but vigilance is needed as post-embolization syndrome can occur in up to 68% of the patients and 20% will need a nephrectomy. In patients with no contraindication to surgery, nephrectomy remains an appealing approach especially where rapid immunosuppression withdrawal is desired. However, the literature is not uniform when it comes to the pros and cons of a nephrectomy after graft failure. Conclusion: While embolization offers a rapid solution to patients with GIS, a close monitoring should be kept, and physicians should adopt a low threshold for surgical nephrectomy.