Optimizing Renal Allograft Dysfunction Management: A Systematic Review and Proposed Algorithm for Interventional...

Kidney transplantation is the optimal treatment for end-stage renal disease, yet post-transplant complications remain a major threat to graft survival. Interventional radiology (IR) has emerged as a minimally invasive alternative to surgery, but the comparative evidence base is fragmented and limited.

This systematic review synthesized evidence from 12 studies, conducted in accordance with PRISMA guidelines, to evaluate the effectiveness of IR versus surgical management of vascular, urological, and lymphatic complications after kidney transplantation.

All included studies were retrospective and single-center, with a moderate to high risk of bias. Despite this, IR consistently demonstrated high technical (94%-100%) and clinical success rates, particularly for transplant renal artery stenosis (TRAS), where endovascular interventions improved renal function and blood pressure control, achieving superior graft survival compared to conservative management. For ureteric complications, IR provided immediate functional recovery, but 38% required surgical conversion, with surgery delivering superior durability in long or fibrotic strictures. In cases of lymphatic complications, percutaneous drainage was effective as a first-line measure; however, surgical fenestration achieved lower recurrence rates (<15%).

The current evidence suggests that IR should be considered the first-line treatment for many vascular and urological complications, while surgery remains indispensable for complex or recurrent cases. The proposed algorithm is applicable to both adult and pediatric recipients, though pediatric cases require tailored approaches due to anatomical and physiological differences. This review is the first to consolidate existing evidence into a complication-specific, stepwise management algorithm, providing a structured clinical framework for decision-making. Prospective, multicenter validation is urgently needed; however, adoption of this algorithm could reduce graft loss, optimize healthcare resources, and redefine standard practice in managing renal allograft dysfunction.