What happens when a graft fails? A comprehensive guide

September 23, 2025 •

5 min read

According to the National Marrow Donor Program (NMDP), graft failure is a rare but serious complication, occurring in less than 5% of allogeneic hematopoietic stem cell transplants. A graft fails when the transplanted tissue or cells do not properly integrate or function within the recipient's body, leading to significant health consequences and complications.

Quick Summary

A graft failure, where transplanted tissue or cells don't integrate, can lead to severe complications like infection, necrosis, and organ dysfunction, necessitating further medical intervention such as additional treatments or repeat transplantation.

Key Points

Causes Vary by Graft Type: Graft failure results from different issues depending on the transplant, such as immune rejection for organs and stem cells, or poor blood supply for skin grafts.
Signs Can Be Localized or Systemic: A skin graft failure may present with visible discoloration and fluid buildup, while an organ or bone marrow failure can cause systemic symptoms like fever, fatigue, and low blood cell counts.
Early Detection is Vital: Recognizing symptoms like discoloration, persistent pain, or flu-like signs early is critical for a better prognosis and effective intervention.
Treatment Depends on the Cause: Management strategies range from debridement and wound care for skin grafts to complex immune-modulating therapies or repeat transplantation for organ and stem cell failures.
Patient Vigilance and Follow-up are Crucial: Consistent monitoring and follow-up with the medical team are essential for long-term graft survival and managing the risks associated with transplantation.
Prognosis is Dependent on Many Factors: A patient's outcome after graft failure is influenced by their underlying health, the type of transplant, and how quickly they receive treatment, but options are available to help navigate this complication.

Understanding Graft Failure: The Basics

A graft is any tissue or organ transplanted from one site to another to replace damaged or missing tissue. When this process is unsuccessful and the transplanted material does not thrive, it is called graft failure. The outcomes and causes of failure vary significantly depending on the type of graft involved, whether it's a skin graft, bone marrow, or a solid organ.

Types of Graft Failure and Their Consequences

The consequences of a failing graft are dictated by the specific type of transplant. For a skin graft, failure typically results in delayed wound healing and chronic, unclosed wounds. With a hematopoietic stem cell transplant (HSCT), graft failure can cause a severe lack of new, healthy blood cells, a condition known as pancytopenia. For a solid organ transplant, failure means the organ stops functioning, potentially leading to a life-threatening crisis.

Causes Behind a Failing Graft

Several factors can contribute to graft failure, and they often overlap. For skin grafts, insufficient blood supply, infection, or excessive movement can prevent proper adherence and revascularization. For organ and stem cell transplants, the primary cause is often immune-mediated rejection, where the recipient's body attacks the donor cells. Other causes include inadequate stem cell dose, infection, damage to the surrounding tissue, or underlying health conditions in the recipient.

Recognizing the Signs and Symptoms

Identifying graft failure early is crucial for timely intervention. The signs can be localized to the graft site or present as systemic symptoms, such as fever, chills, and fatigue.

Symptoms of a Failing Skin Graft

A failing skin graft may display several visible signs at the surgical site:

Discoloration: The graft may turn gray, black, or dark, indicating necrosis (tissue death). Healthy grafts are typically pink and have good capillary refill.
Increased pain and swelling: While some discomfort is normal, persistent or worsening pain, along with redness, can signal infection or poor healing.
Fluid buildup: The accumulation of pus, blood (hematoma), or clear fluid (seroma) beneath the graft can mechanically lift it off the wound bed, preventing it from taking.
Delayed or absent healing: The graft may peel off or fail to integrate with the surrounding tissue.

Symptoms of a Failing Bone Marrow (HSCT) Graft

With HSCT, graft failure leads to a drop in blood cell counts and an increased risk of infection. Symptoms can include:

Pancytopenia: A low count of all major blood cell types, which can be identified through blood tests.
Fever and chills: Often signs of an infection, which the weakened immune system is unable to fight.
Persistent fatigue: The body's inability to produce healthy blood cells can cause extreme tiredness and weakness.
Increased bleeding or bruising: Low platelet counts can lead to easy bleeding and bruising.

Symptoms of a Failing Solid Organ Transplant

Each organ has specific signs of failure, but general symptoms often include:

Flu-like symptoms: Nausea, vomiting, fever, and chills.
Pain or swelling: Near the transplant site.
Decreased organ function: This is measured through lab tests and can manifest as reduced urine output for a kidney or jaundice for a liver.

Next Steps and Treatment Options

If graft failure is suspected, immediate medical evaluation is necessary. The specific treatment depends on the type of graft and the underlying cause of failure.

For Skin Graft Failure

If the failure is due to fluid buildup or infection, treatment may involve:

Debridement: Removing the failed graft and any necrotic tissue.
Wound care: Cleaning and dressing the wound bed to promote a healthy healing environment.
Antibiotics: Administered to treat any underlying infection.
Repeat grafting: A second skin graft may be performed once the wound bed is properly prepared.

For Organ or Bone Marrow Transplant Failure

In these more complex cases, treatment is more intensive and often focuses on controlling the immune response or finding another suitable donor.

Intensified immunosuppression: In some cases, increasing immunosuppressant medication may help control rejection.
Donor Lymphocyte Infusion (DLI): For HSCT, a DLI may be given to boost the donor cells' ability to fight the recipient's remaining immune cells or cancer.
Re-transplantation: For solid organs or HSCT, a second transplant is often the most definitive treatment, though it carries its own set of risks.
Clinical trials: Patients may be eligible for clinical trials investigating new treatments for graft failure.

The Path to Recovery and Long-Term Outlook

Recovering from graft failure can be a long and emotionally challenging process. Prognosis varies widely depending on the patient's overall health, the type of graft, and the cause of failure. However, with proper medical care, many patients can achieve a positive outcome.

The Importance of Surveillance and Follow-up

Ongoing monitoring is critical after any transplant to detect signs of rejection or failure early. Frequent blood tests and imaging help the medical team track the graft's function and respond quickly to any changes. This vigilance is a key factor in ensuring long-term graft survival. You can learn more about managing post-transplant health from reliable sources such as this resource from Temple Health.

Comparison of Graft Failure in Different Transplant Types


Feature	Skin Graft Failure	Bone Marrow (HSCT) Graft Failure	Solid Organ Graft Failure
Primary Cause	Poor vascularity, infection, mechanical stress	Immune rejection, infection, inadequate stem cell dose	Immune rejection, ischemic injury, chronic fibrosis
Key Signs	Discoloration, peeling, fluid buildup, delayed healing	Pancytopenia, fever, increased bleeding/bruising	Flu-like symptoms, pain, decreased organ function
Initial Treatment	Debridement, wound care, antibiotics	Growth factor administration, DLI, blood transfusions	Intensive immunosuppression, possible plasmapheresis
Long-Term Treatment	Repeat skin graft or flap surgery	Salvage HSCT, new conditioning regimen, alternative donor	Re-transplantation, supportive care, clinical trials
Patient Impact	Chronic wounds, scarring, potential contractures	High risk of infection, bleeding, and mortality	Organ dysfunction, potential for life-threatening crisis

Conclusion

Graft failure is a serious and complex medical complication that can occur after various transplant procedures. By understanding the specific symptoms, potential causes, and available treatment options for different types of grafts, patients and their families can be better prepared to recognize the signs and seek immediate medical attention. While graft failure presents a significant challenge, advancements in medical care and vigilant follow-up significantly improve the chances of a positive outcome. The collaborative efforts of a dedicated medical team, from diagnosis to re-transplantation, are vital to navigate this difficult process and restore health.

Frequently Asked Questions

The primary sign of a failed skin graft is often discoloration, such as the graft turning gray, black, or dark, indicating a lack of blood supply and tissue death. It may also show persistent swelling, pain, or fluid buildup underneath.

Yes, survival after a bone marrow graft failure is possible, although it is a serious complication. Treatment options often include a second transplant with cells from the same or a different donor, or other therapies like a donor lymphocyte infusion (DLI). Prognosis depends on the underlying disease and the patient's overall health.

Graft rejection is often an immune-mediated process. The recipient's immune system identifies the donor tissue or cells as foreign and mounts an attack to destroy them. This is more common in solid organ and stem cell transplants, particularly if there is a poor match between the donor and recipient's immune systems.

A failing graft is diagnosed through a combination of physical examination, lab tests, and imaging. For skin grafts, the appearance and healing process are assessed. For organ transplants, blood tests monitor organ function. For stem cell transplants, blood tests monitor the new blood cell production.

If you suspect graft failure, the first and most critical step is to contact your medical or transplant team immediately. They will perform a thorough evaluation and determine the appropriate course of action based on the type of graft and your specific symptoms.

The incidence of graft failure varies widely depending on the type of transplant. For allogeneic hematopoietic stem cell transplants, it occurs in less than 5% of cases. With modern medicine, many types of grafts have high success rates, but failure remains a known risk.

Long-term consequences of graft failure can include chronic wounds and scarring (skin grafts), a higher risk of infection and mortality (HSCT), and the need for re-transplantation or ongoing medical support (solid organs). The specific outcome is highly dependent on the medical response and the patient's individual circumstances.