Indian Journal of Transplantation

ORIGINAL ARTICLE
Year
: 2019  |  Volume : 13  |  Issue : 4  |  Page : 273--276

Lymphocele complications following renal transplantation


Rajendra B Nerli1, Deole Sushant2, Shridhar C Ghagane3, Sreeharsha Nutalpati2, Shyam Mohan2, Neeraj S Dixit3, Shivayogeeswar Neelagund4, Murigendra B Hiremath5,  
1 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University); KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
2 Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belagavi, Karnataka, India
3 Department of Urology, KLES Kidney Foundation, KLES Dr. Prabhakar Kore Hospital and Medical Research Centre, Belagavi, Karnataka, India
4 Department of Biochemistry, Kuvempu University, Shivamogha, Karnataka, India
5 Department of Biotechnology and Microbiology, Karnatak University, Dharwad, Karnataka, India

Correspondence Address:
Dr. Rajendra B Nerli
Department of Urology, JN Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), JNMC Campus, Nehru Nagar, Belagavi - 590 010, Karnataka
India

Abstract

Introduction: Lymphocele formation following renal transplantation is a well-known complication. Mostly these are small and inconsequential, but large lymphocele may cause symptoms like pain, infection , renal dysfunction, surgical drainage of lymphatics Surgical damage of the lymphatics of the graft during the procurement and of the lymphatics around the iliac vessels of the recipients has been responsible with development of lymphocele. Several factors such as diabetes, obesity, blood coagulation abnormalities, anticoagulation prophylaxis, high dose of diuretics, delay in graft function and immunosuppressive drugs are known to be related to these complications. We report three cases of symptomatic lymphoceles managed at our centre during the past one year. Patients and Methods: We retrospectively reviewed patients undergoing renal transplant at our centre. Out of 18 transplant recipients 3 cases developed large symptomatic lymphoceles. These were evaluated by Computed Tomography (CT) scan/ Ultrasound (USG) and serum creatinine levels. These patients were managed by ultrasound guided aspiration and instillation of doxycyline. Results: All three patients underwent USG guided aspiration and doxycyline instillation had significant reduction in serum creatinine levels with no recurrence of lymphoceles on follow-up. Conclusions: lymphocele remains important surgical complications following renal transplantation. Prompt diagnosis and early intervention is crucial to prevent permanent renal damage..



How to cite this article:
Nerli RB, Sushant D, Ghagane SC, Nutalpati S, Mohan S, Dixit NS, Neelagund S, Hiremath MB. Lymphocele complications following renal transplantation.Indian J Transplant 2019;13:273-276


How to cite this URL:
Nerli RB, Sushant D, Ghagane SC, Nutalpati S, Mohan S, Dixit NS, Neelagund S, Hiremath MB. Lymphocele complications following renal transplantation. Indian J Transplant [serial online] 2019 [cited 2020 Jun 4 ];13:273-276
Available from: http://www.ijtonline.in/text.asp?2019/13/4/273/274607


Full Text



 Introduction



The most common early surgical complications following renal transplantation include infection, bleeding, vascular thrombosis, urinary leak, and lymphatic leak. The signs and symptoms of these surgical complications are similar to immunologic causes of graft dysfunction, and therefore, it is important to consider these causes as well.[1]

Lymphocele has been defined as a lymph-filled collection in the retroperitoneum without an epithelial lining.[2] In a patient undergoing a renal transplant, lymphocele is a pseudocystic entity with lymph content covered with a hard, fibrous capsule frequently localized around the graft.[3],[4] Lymphoceles usually originate from the transplanted kidney or from the lymphatic channels that surround the iliac vessels. Most of these lymphoceles are small and inconsequential, but large lymphoceles may cause pain, become infected, or compress the allograft, leading to renal dysfunction. Lymphoceles are well visualized on ultrasound and can be easily treated with image/ultrasonography-guided aspiration. Lymphoceles that are large or reaccumulate usually require insertion of a closed suction drain. Rarely, a recurrent lymphatic leak may require the use of sclerosing agents or even creation of a peritoneal window to aid in reabsorption.[1]

The incidence of lymphocele varies according to the presence or absence of symptoms, size, and duration of the patient's follow-up after transplantation. Introduction of ultrasound evaluation over the past few decades has increased the diagnosis and consequently the incidence of lymphocele, especially of the asymptomatic ones. The reported incidence of symptomatic lymphocele ranges from 0.03% to 26% with a mean of 5.2%.[5] A lymphocele may occur from 2 weeks to 6 months after transplantation with a peak incidence at 6 weeks.[3],[6] We report three cases of symptomatic lymphoceles managed at our center during the past 1 year.

 Material and Methods



We retrospectively reviewed patients undergoing renal transplant at our centre. Out of 18 transplant recipients 3 cases developed large symptomatic lymphoceles. These were evaluated by Computed Tomography (CT) scan/Ultrasound (USG) and serum creatinine levels. These patients were managed by ultrasound guided aspiration and instillation of doxycyline.

The patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity. The study has been approved by Institutional ethics Committee name: KLES Kidney Foundation Institutional Ethical Committee: KLESKFIEC/2019/0013.

 Results



Case report 1

A 51-year-old male underwent deceased donor renal transplantation. The perinephric drain was removed on the 6th postoperative day as the perinephric drain had decreased to <50 ml/day for 3 consecutive days. The patient was discharged from the hospital on the 8th postoperative day with a creatinine of 1.29 mg%. The patient was hypertensive and obese with marginally high Body Mass Index (27). Tacrolimus was used for immunosuppression along with prednisolone and Mycophenolate Mofetil (MMF) (mycophenolic acid). Tacrolimus levels were elevated (22.3 pg/ml) when assessed on the postoperative day.

A routine abdominal ultrasonography done 2 weeks after surgery showed a collection of fluid around the graft. Computed tomography showed a well-defined collection of fluid measuring 6.4 cm × 19.5 cm × 9.0 cm [Figure 1]. The patient was followed up with repeated ultrasonography examination. Serum creatinine was elevated to 1.92 mg%. Ultrasound-guided aspiration of the lymphocele (360 ml) was done. The serum creatinine dropped to 1.49 mg% within 24 h, and the tacrolimus level was 18 pg/ml. The patient has been on close follow-up with repeat ultrasonography examinations. The serum creatinine has been around 1.34 mg% since then.{Figure 1}

Case report 2

A 28-year-old male underwent live-related donor renal transplant and he was put on immunosuppression consisting of tacrolimus, prednisolone, and MMF. The patient presented with a huge asymptomatic lymphocele 5 weeks following transplant and was diagnosed on routine postoperative abdominal sonography. Computed tomography of the abdomen revealed a large collection in the right lower abdomen measuring 8 cm × 13.5 cm × 7 cm [Figure 2]. Serum creatinine was 3.5 mg%. The patient underwent ultrasound-guided aspiration and insertion of a pigtail catheter by the interventional radiologist. The lymphocele fluid showed 0 red blood cell/hpf, glucose of 114 mg%, and proteins of 1.7 mg%, and the fluid culture showed no growth of organisms. The drain reduced to 0 ml 3 days later, and the pigtail catheter was removed. Repeat ultrasound examination done a week later showed recollection of the lymphocele. The patient was taken up for ultrasound-guided aspiration with instillation of doxycycline (sclerosing agent). Postaspiration, the collection did not appear over a follow-up period of 6 months, and his last serum creatinine was 1.4 mg%.{Figure 2}

Case report 3

A 33-year-old obese woman underwent live-related donor renal transplant. Postoperatively, serum creatinine settled around 0.90 mg%. The patient presented with a huge asymptomatic lymphocele 6 weeks later, measuring 12 cm × 9 cm × 7.5 cm and was diagnosed on routine postoperative sonography [Figure 3]. Serum creatinine was elevated to 2.8 mg%. The patient underwent ultrasound-guided aspiration with the instillation of doxycycline. Postaspiration, the serum creatinine levels dropped to 0.95 mg%. This patient too is on close follow-up with repeat ultrasonography performed every month.{Figure 3}

Discussion

The Japanese literature has been the source for the term “lymphocele” (lymphatic collection without an epithelial lining).[7] Lymphocele is frequently found following renal transplantation. The occurrence of lymphocele is caused primarily by the extravasation of lymph from the lymphatic vessels injured at the time of preparation of the iliac vessels of the recipient and/or lymphatics from the renal hilum of the donor. No single factor seems to be responsible for the occurrence of lymphocele following the surgery. Several factors in various combinations could contribute to the development of lymphocele, namely leakage of lymph from the recipient lymphatic channels, use of diuretics, obesity, transplanted kidney biopsy, acute rejection, higher dose of corticosteroids, severed lymphatic vessels of donor kidney allograft, functional delay of deceased donor graft, presence of polycystic disease, sirolimus immunosuppression, repeat transplantation, and thromboembolic prophylaxis with low-dose heparin.[8]

Small lymphoceles are usually asymptomatic, are diagnosed only on ultrasonography examination, and need no treatment. To start with, minimally invasive measures should be used to treat lymphoceles.[9] Generally speaking, most lymphoceles resolve spontaneously and do not require any active treatment but rather only a close follow-up. The incidence of lymphoceles requiring treatment varies from 0.04% to 14.6%.[5],[10] It is important to place a surgical drain in the extraperitoneal space during transplantation, as this has shown to decrease the incidence of fluid collection and the need for lymphocele treatment, especially in patients with sirolimus, rapamycin, and ever olimus-based immunosuppression.[11] The drain should be left in place until drainage reduces to <50 mL/day for 2 consecutive days.

In case the lymphocele becomes clinically symptomatic or the volume exceeds 140 mL, treatment is often required. Percutaneous drainage alone or in association with sclerotherapy has proven to be an effective therapy.[12] The effectiveness of aspiration varies between 25% and 41% compared with percutaneous drain placement between 50% and 55%.[10],[13] Several sclerosing agents including fibrin glue, 95% ethanol with the addition of factor XIII and fibrinogen, sodium tetradecyl sulfate, tetracycline, and povidone-iodine have been used. Recurrence rates following the first and second instillation vary from 31% to 37.5% and 18.7%, respectively.[10],[14] However, repeated aspirations may impact the patient's quality of life and increase the risk of infection. Drainage and sclerotherapy has shown to be not effective in patients, with a lymphocele volume exceeding 500 mL.[11]

Laparoscopic fenestration of the lymphocele into the peritoneal cavity has been shown to be a safe and efficient method in the treatment of symptomatic lymphocele.[4] Laparoscopic surgery offers a valid therapeutic option compared with open surgery and aspirates on the basis of the low rate of complication.[4],[10],[14] Laparoscopic surgery is minimally invasive and associated with a shorter time of hospitalization compared with open surgery. Capocasale et al.[15] reported on the use of octreotide (0.1 mg three times a day subcutaneously) in 10 patients with posttransplant lymphorrhea. The patients on octreotide showed shorter hospital stay and minor discomfort.

All the three patients in our series presented with lymphocele associated with renal dysfunction [Figure 4]. Only aspiration of lymphocele helped in bringing down the creatinine levels and improving renal function. Bohlouli et al.[16] showed that serum cyclosporine levels were higher in patients with lymph leakage, and all cases of allograft rejection were seen in patients with lymph leakage.{Figure 4}

 Conclusions



Lymphatic complications specifically lymphocele remains an important surgical complication following renal transplantation due to dissection of the lymphatics of the recipients and the graft. Transplant surgeons must pay particular attention during both organ retrieval and “back table” work to avoid the dissection of the lymphatic vessels of the kidneys. Placement of drains during surgery acts as the best prevention for lymphocele complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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