Nephrotoxic acute renal failure in a renal transplant patient with recurrent lymphocele treated with povidone-iodine irrigation

Associations among environmental exposure to trace elements and biomarkers of early kidney damage in the pediatric population

BACKGROUND

In kidney damage, molecular changes can be used as early damage kidney biomarkers, such as Kidney Injury Molecule-1 and Neutrophil gelatinase-associated lipocalin. These biomarkers are associated with toxic metal exposure or disturbed homeostasis of trace elements, which might lead to serious health hazards. This study aimed to evaluate the relationship between exposure to trace elements and early damage kidney biomarkers in a pediatric population.

METHODS

In Tlaxcala, a cross-sectional study was conducted on 914 healthy individuals. The participants underwent a medical review and a socio-environmental questionnaire. Five early damage kidney biomarkers were determined in the urine with Luminex, and molybdenum, copper, selenium, nickel, and iodine were measured with ICP-Mass.

RESULTS

The eGFR showed a median of 103.75 mL/min/1.73 m2. The median levels for molybdenum, copper, selenium, nickel, and iodine were 24.73 ng/mL, 73.35 ng/mL, 4.78 ng/mL, 83.68 ng/mL, and 361.83 ng/mL, respectively. Except for molybdenum and nickel, the other trace elements had significant associations with the eGFR and the early kidney damage biomarkers. Additionally, we report the association of different exposure scenarios with renal parameters.

DISCUSSION

and Conclusions. Among the explored metals, exposure to Cu and iodine impairs renal function. In contrast, Se may manifest as a beneficial metal. Interactions of Mo-Se and Mo-Iodine seem to alter the expression of NGAL; Mo-Cu for CLU; Mo-Cu, Mo-Se, and Mo-iodine for Cys-C and a-1MG; and Mo-Cu and Mo-iodine for KIM-1; were noticed. Our study could suggest that trace element interactions were associated with early kidney damage biomarkers.

Sclerotherapy of the Post renal Transplant Lymphoceles: A Meta-Analysis

PURPOSE

This study evaluated the effectiveness of sclerotherapy in treating lymphoceles after kidney transplantation, focusing on factors such as recurrence rates and procedural success.

MATERIALS AND METHODS

Retrospective studies using sclerotherapy as the only form of treatment for postrenal transplant lymphoceles were included. All studies used percutaneous transcatheter sclerotherapy as treatment, and the success rate of the intervention was recorded. Sixty-one references were obtained by manually searching the MEDLINE (n = 20), Embase (n = 41), and Cochrane Library databases (n = 0) for retrospective research studies that included the keywords "sclerotherapy post renal transplant lymphoceles." After removing 3 duplicates, 50 of the remaining articles were excluded after the screening, and the remaining studies were extracted for demographic data and our primary outcome of the success rate of sclerotherapy.

RESULTS

A descriptive analysis of the outcomes and complication rates associated with sclerotherapy interventions for lymphoceles is provided. A high degree of variation across the different studies was observed. According to the Kruskal-Wallis test, there was no correlation between the sclerosant used and the sclerotherapy complication rate (P = .472) or the success rate (P = .591). There was also no correlation between the gender of the patient and the success rate; however, there was a significant difference in the complication rate by gender (P < .005).

CONCLUSIONS

In conclusion, different sclerosant products have been used for therapy with no consensus on the most efficacious product because the success rate has been variable. In addition, the gender of the patient may influence the complication rates associated with sclerotherapy for lymphoceles in patients post-kidney transplant.

Cell death and barrier disruption by clinically used iodine concentrations

Povidone-iodine (PVP-I) inactivates a broad range of pathogens. Despite its widespread use over decades, the safety of PVP-I remains controversial. Its extended use in the current SARS-CoV-2 virus pandemic urges the need to clarify safety features of PVP-I on a cellular level. Our investigation in epithelial, mesothelial, endothelial, and innate immune cells revealed that the toxicity of PVP-I is caused by diatomic iodine (I2), which is rapidly released from PVP-I to fuel organic halogenation with fast first-order kinetics. Eukaryotic toxicity manifests at below clinically used concentrations with a threshold of 0.1% PVP-I (wt/vol), equalling 1 mM of total available I2 Above this threshold, membrane disruption, loss of mitochondrial membrane potential, and abolition of oxidative phosphorylation induce a rapid form of cell death we propose to term iodoptosis. Furthermore, PVP-I attacks lipid rafts, leading to the failure of tight junctions and thereby compromising the barrier functions of surface-lining cells. Thus, the therapeutic window of PVP-I is considerably narrower than commonly believed. Our findings urge the reappraisal of PVP-I in clinical practice to avert unwarranted toxicity whilst safeguarding its benefits.

Povidone-Iodine-Induced Acute Kidney Injury in a 23-Year-Old Woman: The First Clinical Case Report From the Republic of Cyprus

Povidone-iodine (PI) is considered a generally safe broad-spectrum, antiseptic substance, which is widely used in healthcare services, mostly for burn patients, in wound treatment, surgical wound irrigation, as well as for a few gynecological indications. Although it is safe, its use on mucosa can cause toxicity due to iodine absorption and the high concentration in the serum. PI toxicity is absorption depended and has been associated with severe adverse events including acute kidney injury (AKI). To our knowledge, there are only three cases of PI-induced AKI after uterine instillation in the published literature. We report a case of severe PI-induced AKI that occurred in a 23-year-old female due to iodine systemic absorption immediately post uterine instillation, in terms of infertility evaluation.

The patient was admitted to the intensive care unit (ICU), supported with mechanical ventilation and treated with renal replacement therapy (RRT). Renal function and urine output improved and the patient was discharged from ICU.

Severe adverse events may be linked to internal use, therefore, PI on mucosa should be used with extreme caution. Clinicians should be aware of iodine intoxication and possible AKI.

Histological microaggregates as a sign of systemic dissemination due to oral ingestion of povidone-iodine (Betadine®)

Povidone-iodine (PVP-I) in the formulation of Betadine® is widely used in several medical fields, whereas its suicidal ingestion is an unusual occurrence. Therefore, the biological signs of this fatal poisoning remain unclear and elusive, similarly to the histological lesions induced by PVP-I. In fact, there are no forensic articles concerning the histological signs of PVP-I acute poisoning. Specifically, this short communication reports the unique case of a man who ingested 125 ml of Betadine® 10% to commit suicide, for which he died three days later. The autopsy examination showed either local or systemic signs of caustic ingestion; moreover, the histological analysis showed both intra- and extra-cytoplasmic amorphous and brownish microaggregates in almost all the organs. Histological and histochemical techniques resulted to be negative for the detection of physiological and known pigments (e.g., formalin, lipofuscin, hemosiderin). Likewise, such pigments were not associated neither with the man's diseases nor with his medications. Therefore, the authors supposed that they were povidone-iodine microaggregates, which have been deposited in the organs through the blood circulation. In conclusion, the complete postmortem histological examination could allow the identification and the characterization of PVP-I microaggregates as evidence of systemic toxicity from Betadine®, when dealing with a forensic case of ingestion of povidone-iodine.

Predictors of Lymphatic Complications Following Renal Transplant: A Prospective Study Involving Predominantly Living Donor Transplants From India

Introduction Lymphatic complications (LC) are common (up to 33%) and troublesome after renal transplantation. Different studies have established varying medical and surgical risk factors, mostly by retrospective analysis on deceased donor renal transplants (DDRTs). The end-point is mostly lymphocele, with few reports documenting the equally important lymphorrhea. Methods In our prospective analytical study done over three years, most were living donor renal transplant (LDRT) pairs by a single team. The primary outcome measure was lymphocele and/or prolonged drainage for more than 15 days, with a six-month follow-up. The variables recorded were age, gender, hemodialysis duration, etiology, relationship, human leucocyte antigen (HLA) mismatch, induction regimen, acute rejection, warm ischemia time (WIT), and delayed graft function (DGF). Univariate analysis was by chi-square and t-tests as applicable, while logistic regression (both simultaneous and forward stepwise) was used for risk factor prediction. Results Eligible cases were 150, with 145 (97%) LDRT pairs. Donors were mostly female (122/150; 81%) with mean age (~43 years) higher than recipient age (~33 years). The common etiologies were diabetes (31%), hypertension (23%), and IgA nephropathy (11%). Most donors were mothers (37%) and wives (31%), and 28% of LDRT pairs had HLA mismatch >3. Mean duration of hemodialysis was about 18 months, and mean WIT was 52 minutes. Both DGF (B coefficient= -1.69, p<0.000) and WIT (B=-0.038, p=0.024) were significant predictors of the primary outcome, while drain removal before 15 days predicted lymphocele significantly (B=-2.4, p<0.000).  Conclusions LDRT has specific risk factors for lymphatic complications, which may be related to extent of recipient vascular dissection, arterial anastomotic time, and early drain removal.

Povidone Iodine Disinfection Associated with Hypothyroidism and Potentially Contributing to Prolonged Kidney Failure

Objectives

To report a case of povidone-iodine (PVP-I, Iso-Betadine®) disinfection of lower leg fasciotomy wounds resulting in iodide absorption and possibly contributing to hypothyroidism and prolonged kidney injury.

Design

Case report. Setting. Pediatric intensive care unit (PICU), university hospital. Patients. A 13-year-old patient presenting with prolonged oligoanuric kidney failure and unexplained primary hypothyroidism three weeks after severe abdominal sepsis with multiple organ dysfunction and major rhabdomyolysis due to bilateral lower leg compartment syndrome, necessitating moderate size fasciotomies, disinfected daily with PVP-I. Interventions. Interruption of PVP-I exposure and initiation of thyroid hormone substitution. Measurements and Main Results. Hypothyroidism was revealed during diagnostic work-up for persistent hypertriglyceridemia. Thyroxine (T4) (4.0 mg/L) and tri-iodothyronine (T3) (64 ng/L) were moderately low, yet thyroid stimulating hormone (TSH) (16.8 mIU/L) was fourfold the maximal normal range value. This pattern, atypical for prolonged critical illness-related hypothyroidism, prompted interruption of PVP-I exposure and initiation of thyroid hormone substitution. Urinary production and creatinine clearance recovered during the following days, and one week later, intermittent renal replacement therapy could be terminated, suggesting that PVP-I toxicity and/or hypothyroidism may have contributed to the persistent renal failure three weeks after resolved septic shock and rhabdomyolysis. Elevated serum and urinary anion gap normalized simultaneously, but this evolution of rather nonspecific indices could be multifactorial.

Conclusion

PVP-I is a commonly used broad-spectrum antimicrobial agent for prevention and treatment of wound infections. Toxic complications due to PVP-I absorption, after disinfection of extended thermal injuries larger than 20% of the body surface, have been described. In critically ill children, however, toxic effects of PVP-I may occur due to repeated disinfection of less extended wounds. Proposed screening strategies include: monitoring of the volumes of PVP-I applied daily; of the thyroid function, the serum, and/or urinary anion gap and the urinary iodide concentrations. These strategies, however, remain to be validated. This case report should be a wake-up call for daily integration of wound management in the clinical evaluation of critically ill patients.

Experience of Lymphangiography as a Therapeutic Tool for Lymphatic Leakage After Kidney Transplantation

INTRODUCTION

Lymphatic leakage after kidney transplantation is a relatively frequent complication but sometimes resistant to treatment, and there is no fixed treatment algorithm. The effectiveness of therapeutic lymphangiography for postoperative lymphatic or chyle leakage has been reported, but few reports are available regarding patients who have undergone kidney transplantation. In this study, we report our experience with lymphangiography as a therapeutic tool for lymphatic leakage after kidney transplantation.

PATIENTS AND METHODS

Intranodal lymphangiography for lymphatic leakage was performed in 4 patients (3 male, 1 female; age range, 38 to 70 years old) after living kidney transplantation at the Osaka City University Hospital in Japan. The amount of drainage before lymphangiography was 169 to 361 mL/day. The procedure for intranodal lymphangiography was as follows: the inguinal lymph node was punctured under ultrasound guidance, and the tip of the needle was instilled at the junction between the cortex and the hilum, after which Lipiodol was slowly and manually injected.

RESULTS

Lymphangiography was technically successful in 3 out of the 4 patients. In all successful cases, the amount of drainage decreased and leakage finally stopped without additional therapy such as sclerotherapy or fenestration. In 2 cases, we were able to directly detect the leakage site using lymphangiography. The time between lymphangiography and leakage resolution ranged from 8 to 13 days. There were neither complications of lymphangiography nor recurrence of lymphatic leakage in the successful cases.

CONCLUSIONS

Intranodal lymphangiography may be not only a diagnostic tool but also an effective, minimally-invasive, and safe method for treatment of lymphatic leakage resistant to drainage after kidney transplantation.

Acute kidney injury due to povidone-iodine ingestion: A case report

RATIONALE

Povidone-iodine is a broad-spectrum antiseptic applied topically to treat wounds and prevent their infection. There have been several case reports of acute kidney injury (AKI) in burn patients after povidone-iodine irrigation and in patients receiving the substance as a sclerotherapy agent for management of lymphocele after renal transplantation. However, biopsy-confirmed AKI after ingestion of povidone-iodine has not previously been described.

PATIENT CONCERNS

A 47-year-old man who had apparently ingested povidone-iodine solution and presented with nausea, vomiting, and reduced urine output. Laboratory data revealed blood urea nitrogen of 124 mg/dL, serum creatinine of 6.3 mg/dL, impaired liver function, and leukocytosis. Urine iodine/creatinine ratio was markedly elevated.

DIAGNOSES

Acute tubular necrosis and interstitial nephritis secondary to povidone-iodine ingestion.

INTERVENTIONS

The patient was admitted to the intensive care unit and underwent continuous venovenous hemodiafiltration. Kidney biopsy showed acute tubular necrosis and interstitial nephritis. Unstained sections showed tan objects in the tubular lumina that were suspected to be povidone-iodine casts. Corticosteroid therapy (1 mg/kg/day) was started after kidney biopsy.

OUTCOMES

Renal function recovered after hemodialysis and corticosteroid medication, but not completely.

LESSONS

We have reported the first case of biopsy-confirmed AKI accompanied by increased urine iodine concentration following povidone-iodine ingestion.

Povidone-iodine-induced cell death in cultured human epithelial HeLa cells and rat oral mucosal tissue

Although povidone-iodine (PVP-I) has been used as a gargle since 1956, its effectiveness and material safety have been remained controversial. The aim of this study was to investigate the toxicity of PVP-I to epithelial cells in a concentration range significantly lower than that used clinically. Study design was in vitro laboratory investigations and in vivo histological and immunologic analysis. We examined the effects of PVP-I at concentrations of 1 × 10(-2) to 1 × 10(3) μM and 1 × 10(-4) to 1 × 10 μM on HeLa cells as a model of epithelial cells and rat oral mucosa, respectively, after 1 or 2 days of exposure. Annexin V/FLUOS was used to distinguish live, apoptotic and necrotic cells. The terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) method was also used to observe whether apoptotic epithelial cells exist in rat oral mucosa after 1 day of exposure of PVP-I. HeLa cells developed concentration-dependent cytotoxicity, and epithelium of rat oral mucosa was thinned in a concentration-dependent manner. HeLa cell apoptosis increased after 1 × 10(0) μM of PVP-I exposure for 2 days. In the TUNEL method, many apoptotic epithelial cells were observed in the rat oral mucosa after 1 day of exposure to diluted 1 × 10(-2) μM of PVP-I, but minimal apoptotic epithelial cells were observed using 1 × 10(-3) μM of PVP-I. Our findings suggest that exposure to PVP-I, of which concentrations are even lower than those used clinically, causes toxicity in epithelial cells. This knowledge would help us better understand the risk of the use of PVP-I against mucosa.

Refractory and massive lymphocele in a transplant patient with encapsulating peritoneal sclerosis treated with a single infusion of bleomycin: a case report

A 26-year-old Caucasian man developed a large lymphocele after living-related kidney transplantation necessitating repeated drainage of large volumes every other day owing to ureteral compression. An open laparotomy for internal drainage was unsuccessful because of severe encapsulating peritoneal sclerosis. Prolonged external drainage with a catheter was inefficient. Repeated fine-needle aspirations of large volumes were needed to maintain ureteral patency over a period of 4 months. Finally, a single instillation of bleomycin immediately and effectively treated the lympocele with no relapse over the following 5 years. The presence of encapsulating peritoneal sclerosis seemed to be an obstacle to surgical treatment.

Laparoscopic treatment of lymphoceles after renal transplantation

OBJECTIVE

Lymphocele formation following renal transplantation is a frequent complication and may affect as many as 49% of patients. Operative treatment of symptomatic post transplant lymphocele (PTL) consists of wide drainage of the fluid collection into the abdominal cavity by excising its wall, connecting the lymphocele cavity to the intraperitoneal space. Laparoscopic fenestration seems to be the best treatment as it combines satisfying success rates with a minimally invasive approach. The aim of the study was to review a single center experience on the laparoscopic treatment of symptomatic PTL and detail relevant aspects of the surgical technique.

MATERIALS AND METHODS

The data of 25 patients who underwent laparoscopic surgical treatment for a symptomatic lymphocele following kidney transplantation were retrospectively reviewed. Demographic data and surgical results were assessed. Detailed surgical technique is provided.

RESULTS

Between 1996 and 2008, 991 patients received a kidney transplant at our institution. Twenty-five patients (2.52%) developed a symptomatic lymphocele and laparoscopic drainage was performed. The indications for surgical drainage were graft dysfunction (84%), local symptoms (16%) or both (32%). The mean time until surgical therapy was 14.2 ± 6 weeks. Mean hospital stay was 1.5 ± 0.2 days. Postoperative complications occurred in only 2 patients (8%) (one ureteral injury and one incisional hernia) and required reoperation. After a mean followup of 36.2 ± 4 months, only 1 patient had a symptomatic recurrence.

CONCLUSIONS

Laparoscopic fenestration is an effective surgical technique to treat symptomatic lymphocele following kidney transplantation with low recurrence rate and long standing results.

Does ultrasonic energy for surgical dissection reduce the incidence of renal transplant lymphocele?

OBJECTIVE

To determine the difference in post-renal transplant lymphocele rate based on the surgical dissection technique for control of lymphatics by examining the historical case group under the direction of a single, university-based surgeon in a retrospective, cohort study.

PATIENTS

Five hundred thirty-two consecutive renal transplant patients from January 1994 to December 2009.

FINDINGS

Of the 532 cases studied, 259 (48.7%) had suture ligation and 273 (51.3%) employed ultrasonic dissection (UD) for control of lymphatics during renal transplantation. There was no difference found in the rate of lymphocele formation, requiring either percutaneous or surgical drainage, when surgical ties (8.9%) were compared to UD (9.2%; P=.999). Logistic regression analysis showed that the odds ratio for developing a lymphocele was independent of surgical dissection technique. Within the logistic analysis, the prediction for lymphocele was increased 3.29 times for pediatric patients (P=.002) and increased 2.97 times for those who received a living donor graft (P=.001), and there was a trend for those with a history of more than one renal transplant of 2.01 times (P=.079).

SUMMARY

Surgical dissection technique was not a factor in the development of post-renal transplant lymphocele. Younger age, living donor transplant, and repeat transplant status were found to be predictive variables for symptomatic lymphoceles requiring drainage, which may be considered when patients present for posttransplant evaluations for laboratory alterations.

Perirenal transplant fluid collections

Various collections can develop in the space surrounding a renal transplant. These collections can present at any point in time from the immediate post transplant period to several months post transplantation and can be incidental or cause significant transplant dysfunction. The use on computed tomography and ultrasound allows for the imaging characteristics of these collections and their relationship to the transplanted kidney to be easily characterized. Standard means of percutaneously accessing the collections to obtain fluid is instrumental in diagnosing their etiology. Urinomas, hematomas, seroma, lymphomas and abscesses can be seen. The management of these collections is dependent on the nature of the peritransplant collection. Optimal care of patients with peritransplant collections is best attained by considered collaboration of a multi-specialty team.

Povidone iodine: features of critical systemic absorption

Povidone iodine (PI), a skin antiseptic, is sometimes used internally but this procedure exposes to potentially lethal iodine absorption. Indeed, a 41-year-old woman, with no relevant medical history, developed a transient hypotension, anuric renal failure, hemolysis, coagulopathy and uterine infarction after intra-uterine injection of PI as a dye to check the fallopian tube patency (hydrotubation). Iodemia peaked at 6929 μg/dL (normal range 3.4-8.0 μg/dL), and decreased over the 9 days of renal replacement therapy. Extreme caution should be exercised when PI is in contact with a mucosa, the early recognition of iodine toxicity being of utmost importance to rapidly prompt renal replacement therapy. The main purpose of this report is to highlight the clinical features of PI absorption, whatever the route of administration.

How to remove accumulated iodine in burn-injured patients

BACKGROUND

Absorption of large quantities of iodine, as induced by the use of topical antimicrobial povidone-iodine in burn-injured patients, may cause metabolic and electrolyte abnormalities as well as renal failure. To diminish iodine levels, haemodialysis was previously reported to be a suitable therapy. We therefore studied the kinetics of iodine in order to define the most optimal dialysis strategy.

METHODS

Two patients with elevated iodine levels (93.6 and 81.2 mg/L) underwent continuous dialysis with blood flows Q(B) 150 and 120 mL/min. Blood was sampled from the inlet and outlet dialysis line at several time points during a 7-h and 39-h 10-min period, respectively. Samples were analysed for iodine with the inductively coupled plasma mass spectrometry (ICPMS) method. Kinetic analysis was performed using one and two compartmental models, deriving kinetic parameters: plasmatic volume V(1), extraplasmatic volume V(2) and intercompartmental clearance K(12). The calibrated kinetic model of Patient 2 was further used to simulate different dialysis strategies: 12-h per day with Q(B) 240, 6-h per day with Q(B) 480 and 240, and 12-h every 2 days with Q(B) 240. For each strategy, the mean average plasmatic and extraplasmatic concentration (TAC(p) and TAC(ep)) was calculated during 48 h.

RESULTS

Iodine seemed to follow one compartmental kinetics when serum sample collections were limited to the first 7 h of dialysis (Patient 1), but iodine appeared to be distributed in two volumes (V(1)=19.4 L, V(2)=38.0 L and K(12)=55 mL/min) when a longer observation period was taken into account (Patient 2). The simulations disclosed that 12-h dialysis per day with Q(B) 240 or continuous dialysis with Q(B) 120 resulted in the lowest TAC(p) (18.2 and 19.0 microg/L) and TAC(ep) (34.4 and 36.1 microg/L).

CONCLUSION

In patients with elevated iodine levels, especially when associated with renal failure, haemodialysis with a minimum 12-h duration with sufficient blood flow should be the first choice to remove iodine.

Did volume of lymphocele after kidney transplantation determine the choice of treatment modality?

INTRODUCTION

Lymphocele is a lymph collection that forms after surgery following injury to lymph nodes and vessels. The aim of the study was to perform a retrospective analysis of different treatment modalities of lymphocele in patients after kidney transplantation.

MATERIAL AND METHODS

A lymphocele located in renal graft area was observed in 25 of 386 transplanted patients (6.5%). Mean patient age was 45 (95% confidence interval [CI], 40 to 50) years. Mean observation time was 35 (95% CI, 27 to 43) months.

RESULTS

Mean time from transplantation to diagnosis of lymphocele was 29 days (range, 4 to 127). In 13 patients (54.2%), the lymphocele was symptomatic, requiring initial treatment by repeated needle aspirations or percutaneous drainage. Among 7 patients with persistence of the lesion treatment by sclerotherapy with doxycycline, povidone-iodine, and/or ethanol was successful in 4 cases who showed maximal lymphocele volume of 500 mL. Three other patients, namely, volumes of 120, 874, and 2298 mL were referred for surgery; in two cases, internal marsupialization was performed and in one case external drainage was necessary due to abscess formation. Mean time from the diagnosis to recovery in patients requiring surgical treatment was 15 (range, 8 to 24) weeks. Eleven patients with asymptomatic lymphoceles (mean volume 45 mL; range, 8 to 140) were monitored to resolution after a mean of 4 (range, 1 to 11) weeks.

CONCLUSION

All lymphoceles with the maximal volume exceeding 140 mL were clinically symptomatic. Initial percutaneous drainage with or without sclerotherapy was an effective method of treatment. Punctures, drainage, and sclerotherapy were not effective in patients with lymphoceles (>500 mL).

Insuffisance rénale aiguë secondaire à la povidone iodée: à propos d'un cas clinique

INTRODUCTION

Using iodine povidone in internal way may be responsible of severe adverse effects, sometimes causing death of the patients.

EXEGESE

A 36th years old woman, with a secondary sterility has benefitted of an uterine opacification by iodine povidone before a laparotomy and a salpingotomy. In post surgery she presented an anuric acute renal failure and a severe anaemia which have needed a transfusion. Outcome was favourable with a recuperation of diuresis and a full normalization of the renal function.

CONCLUSION

The authors recommend to respect the indications of iodine povidone.

Insuffisance rénale aiguë secondaire à la povidone iodée

INTRODUCTION

Povidone iodine is a widely-used antiseptic agent, especially for cutaneous lesions. Despite its apparent innocuousness, some cases of acute renal failure are reportedly due to iodine toxicity.

CASE

We report a case of an acute renal failure secondary to povidone iodine exposure in a 37-year-old woman. She underwent a hysteroscopy for diagnosis of primary sterility, and povidone iodine was used as the contrast agent. She developed acute renal failure with oliguria during the postoperative period. Treatment with diuretics and hemodialysis led to a favorable outcome and return of normal kidney function.

DISCUSSION

Mucosal administration of povidone iodine appears to lead to greater iodine toxicity than cutaneous administration. The clinical feature of our patient suggested tubular necrosis caused by iodine, after the other possible causes of acute renal failure were ruled out.

CONCLUSION

Acute renal failure secondary to povidone iodine administration is possible, especially through mucosal surfaces. Outcome is favorable after the conclusion of exposure and symptomatic treatment.

Radiologic imaging and percutaneous treatment of pelvic lymphocele

Pelvic lymphocele, also known as lymphocyst, is a cystic structure caused by lymphatic injury usually secondary to pelvic lymphadenectomy and renal transplantation. Lymphoceles can cause morbidity and rarely mortality by compression of adjacent structures and infectious complications. This review discusses etiology and treatment options for pelvic lymphoceles including surgical and percutaneous methods with emphasis on percutaneous techniques particularly in conjunction with sclerotherapy. Percutaneous catheter drainage with sclerotherapy procedure with various sclerosing agents is described in detail. Ethanol, povidone-iodine, tetracycline, doxycycline, bleomycin, talc and fibrin glue can be used as sclerosing agents. Combination of sclerosing agents to percutaneous catheter drainage significantly improves success rate in the treatment of pelvic lymphoceles. Infected lymphoceles are usually treated solely with percutaneous catheter drainage. Percutaneous treatment can be tailored according to volume of lymphoceles. We generally prefer single session sclerotherapy and 1 day catheter drainage in lymphoceles less than 150 mL, and larger ones are treated by multi-session sclerotherapy until daily drainage decreases below 10 mL. Percutaneous treatment preferably with sclerotherapy should be considered as the first-line treatment modality for pelvic lymphoceles due to its effectiveness, widespread applicability on an outpatient basis, ease of procedure and low complication rate.

Laparoscopic treatment of post renal transplant lymphoceles

BACKGROUND

Traditionally, a post transplant lymphocele (PTL) is drained by widely opening the wall connecting the lymphocele cavity to the intraperitoneal space via laparotomy. We hypothesize that laparoscopic techniques can be effectively used for the treatment of PTL.

METHODS

Patients requiring intervention for PTL between 1993 and 2002 were identified via a retrospective review. Results of drainage via laparotomy and laparoscopy were compared.

RESULTS

During the study period 685 renal transplants (391 cadaveric, 294 living) were performed. The incidence of lymphocele was 5% [34/685 (36 cases)]. The indications for surgical drainage were local symptoms (69%), graft dysfunction (14%), or both (17%). The mean time to surgical therapy was 4.9 months. Laparoscopic drainage was performed in 25 patients (74%) and open drainage in 9 patients (26%). Open procedures were performed in cases for: previous abdominal surgery (5), undesirable lymphocele characteristics or location (2), or with concomitant open procedures (3). There were no conversions or operative complications in either group. There was no difference in operative time for the laparoscopic group vs the open group (108 +/- 6 vs 123 +/- 18 min, p = 0.8). Hospital stay was significantly shorter for the laparoscopic group (1.7 +/- 0.8 vs 3.8 +/- 1.0, p = 0.0007), with 88% of laparoscopic patients being either overnight admissions or same day surgery. Two patients (5%) developed symptomatic recurrences requiring reoperation [1 laparoscopic (4%), 1 open (10%)].

CONCLUSIONS

Laparoscopic fenestration of a peritransplant lymphocele is a safe and effective treatment. The large majority of patients treated with laparoscopic fenestration were discharged within one day of surgery. Unless contraindications exist, laparoscopy should be considered first-line therapy for the surgical treatment of posttransplant lymphocele.

Iodine toxicity treated with hemodialysis and continuous venovenous hemodiafiltration

Continuous mediastinal irrigation with povidone-iodine is used commonly for treating severe postoperative mediastinitis. However, concurrent iodine toxicity has been reported, particularly in patients with renal dysfunction (likely because absorbed iodine is renally excreted). The authors were consulted on a 45-year-old patient with mediastinitis who had renal and hepatic dysfunction while being treated with mediastinal irrigation of povidone-iodine. The povidone-iodine irrigation was discontinued because he had toxic plasma iodine levels. Despite this, his condition worsened, and the iodine levels remained elevated. Thus, hemodialysis (HD) was initiated using high-flux membranes followed by continuous venovenous hemodiafiltration (CVVHDF; 2 L/h of hemofiltration and 2 L/h of HD). Plasma and effluent iodine levels were measured repeatedly to determine iodine clearance by these 2 modalities (HD, 120 mL/min; CVVHDF, 37 mL and 44 mL/min on days 1 and 2, respectively). Hepatic and renal functions improved with decreasing plasma iodine levels. Based on this experience and after reviewing the literature the authors conclude that: (1) iodine irrigation can increase blood iodine levels significantly, especially in the setting of renal failure, and lead to increased morbidity and mortality; (2) plasma iodine levels should be monitored in patients with renal insufficiency; and (3) HD and CVVHDF are effective at clearing iodine. The authors suggest that patients that are at high risk or already developing signs of iodine toxicity should have the iodine irrigation discontinued and may benefit from renal replacement therapy (RRT). Alternatively, concomitant RRT during iodine irrigation may be attempted to maintain the systemic iodine levels at nontoxic levels.