Severe ascites following renal transplant biopsy caused by a rupture of a subcapsular lymphocele: treated successfully by retroperitonealization

Sir,

We would like to share our experience of a patient who developed subcapsular lymphocele post cadaver transplant from a paediatric patient. Lymphoceles complicate 18% of renal transplants [1]. They usually occur in the first 6 months following transplant [2]. Lymphoceles are usually diagnosed because of pain over the transplanted kidney, or are found incidentally during investigation of renal failure. They may cause ureteric obstruction [3]. Many treatment regimes have been reported including puncture drainage, povidone iodine, ethanol or tetracycline sclerotherapy and internal drainage by surgical or laparoscopic marsupalization. Many times the patient may end up finally losing the transplanted kidney.

A 29-year-old female patient underwent cadaveric transplant from a paediatric donor age 6 years in October 2001 for end-stage renal failure due to hypertensive renal disease. The procedure was uneventful and the kidney functioned well (baseline serum creatinine of 90 µmol/l at 2 weeks). The maintenance immunosupression was tacrolimus and prednisolone.

In August 2002 the patient presented to Accident and Emergency with abdominal pain and an increased serum creatinine (179 µmol/l) raising the suspicion of rejection. She had an ultrasound scan of the abdomen, which showed a large kidney with a small loculated perinephric fluid collection. A renal biopsy showed thrombotic microangiopathy, which was felt to be secondary to tacrolimus. Hence rapamycin was substituted for tacrolimus. Two weeks after the biopsy she was admitted again with grossly distended abdomen. Repeat ultrasound scan showed gross ascites with a normal transplanted kidney. Diagnostic paracentesis was performed and ~1 l of fluid was drained. The ascitic fluid re-accumulated rapidly and repeated paracentesis of 6–8 l were performed over a 2-month period to relieve symptoms of severe abdominal distension. The ascitic fluid showed 1355 WBCs with 95% lymphocytes and TB. PCR (polymerase chain reaction) of the fluid was positive and hence she was started on anti-TB treatment. Whole body CT scanning and the gallium scanning revealed no abnormality other than the ascitic fluid. Lymphangiogram was performed and demonstrated that the lymph appeared to be from the transplanted kidney.

As the ascites persisted she required twice weekly paracentesis for symptoms of paracentesis secondary to distension. The patient underwent laparotomy. She was found to have an enlarged kidney with fluid seeping out through the opening in the capsule (Figure 1). On opening the capsule, fluid gushed out. It became apparent that the patient had a subcapsular lymphocele, which was draining into the peritoneum through a rent in the capsule probably caused at the time of the renal biopsy some months previously. Retroperitonealization of the capsular opening by sewing the ascending colon to the edge as well as continuous intra-abdominal and subcapsular drainage helped in decreasing the drainage over a period of 6 weeks. The patient has made an excellent recovery.



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Fig. 1. Rupture site of the subcapsular lymphocele.

 
Our case of subcapsular lymphocele is the first of its kind to be reported. The delayed presentation is unusual and may have been precipitated by the renal biopsy. Initial treatment with drainage over a prolonged period of time was unsuccessful. The subcapsular lymphocele became evident because of the biopsy, which opened the window to the peritoneum. The technique of retroperitonealizing the lymphocele with colon sutured to the edge of the rent may have helped in absorption of the lymph through the retroperitoneum and thus gradually decreasing the ascites.

Rapamycin has been blamed for an apparent increased incidence of lymphocele in Germany where transplanted kidney of patients treated with rapamycin developed lymphoceles. The authors have been unable to explain theses findings [4].

Conflict of interest statement. None declared.

Shailesh Kulkarni, Aine Burns and Mahmoud Al-Akraa

Wembley London UK Email: kulkarnishailesh{at}hotmail.com

References

  1. Duepree HJ, Fornara P, Lewejohann JC, Hoyer J, Bruch HP, Schiedeck TH. Laparoscopic treatment of lymphoceles in patients after renal transplantation; clinic. Transplant 2001; 15: 375–379[CrossRef]
  2. Thomas TJ, Neale TJ. Acute perirenal lymphocele formation 8 years after renal transplantation. Aust N Z J Surg 1989; 59: 583–585[ISI][Medline]
  3. Martin Xaboutaieb R, Dawahra M, Lagha K et al. Treatment of lymphocele after kidney transplantation. Prog Urol 1996; 6: 260–263[Medline]
  4. Geissing M, Fischer TJ, Deger S et al. Increased frequency of lymphocytes under treatment with birdlimes following renal transplantation: a single centre experience. Transplant Proc 2002; 34: 1815–1816[CrossRef][ISI][Medline]




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