Prophylaxis of lymphocele formation after kidney transplantation via peritoneal fenestration: a systematic review

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.

Prophylactic Peritoneal Fenestration during Kidney Transplantation Can Reduce the Type C Lymphocele Formation

Lymphocele is a common complication following kidney transplantation (KTx). We aimed to evaluate the preventive effect of peritoneal fenestration during KTx in reducing lymphocele. From January 2001, the data of all KTx were prospectively gathered in our digital data bank. From 2008, preventive peritoneal fenestration was performed as a routine procedure for all patients with KTx. Between 2001 and 2008, 579 KTx were performed without preventive peritoneal fenestration. To compare the results between with and without peritoneal fenestration, the same number of patients after 2008 (579 patients) was included in this study. The pre-, intra-, and postoperative data of the patients in these two groups were analyzed and compared, especially regarding the postoperative different types of lymphocele formation. The mean recipient age was 52.6 ± 13.8, and 33.7% of the patients were female. Type C lymphocele was significantly lower in the group with preventive fenestration (5.3% vs. 8.8%, p = 0.014 for 31/579 vs. 51/579). Peritoneal dialysis and implantation of the kidney in the left fossa were independently associated with a higher rate of type C lymphocele (OR 2.842, 95% CI 1.354–5.967, p = 0.006 and OR 3.614, 95% CI 1.215–10.747, p = 0.021, respectively). The results of this study showed that intraoperative preventive peritoneal fenestration could significantly reduce type C lymphocele.

Validating Consensus-Defined Severity Grading of Lymphatic Complications after Kidney Transplant

Lymphatic complications after kidney transplantation (KTx) are associated with morbidities such as impaired wound healing, thrombosis, and organ failure. Recently, a consensus regarding the definition and severity grading of lymphoceles has been suggested. The aim of the present study was to validate this classification method. All adult patients who underwent KTx between December 2011 and September 2016 in our department were evaluated regarding lymphoceles that were diagnosed within 6 months after KTx based on the recent definition. Patients with lymphoceles were categorized according to the classification criteria, and clinical outcomes were compared between the groups. In our department, a total of 587 patients underwent KTx between 2011 and 2016. Lymphoceles were detected after KTx in 90 patients (15.3%). Among these patients, 24 (26.6%) had grade A lymphoceles, 14 (15.6%) had grade B, and 52 (57.8%) had grade C. The median duration times of intermediate care (IMC) and hospital stay were significantly higher among patients with grade C lymphoceles than they were among patients with grade A and B lymphoceles. Significantly more patients with grade C lymphoceles were readmitted to the hospital for treatment. The recently published definition and severity grading of lymphoceles after KTx is an easy-to-use and valid classification system, which may facilitate the comparison of results from different studies on lymphoceles after KTx.

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.

PREventive effect of FENestration with and without clipping on post-kidney transplantation lymphatic complications (PREFEN): study protocol for a randomised controlled trial

INTRODUCTION

Peritoneal fenestration is an effective preventive method for reducing the rate of lymphatic complications in kidney transplantation (KTx). The size of the fenestration plays an important role in its effectiveness. A large peritoneal window is no longer indicated, due to herniation and difficulties in performing biopsies. Small preventive fenestration is effective but will be closed too early. The aim of this study is to evaluate whether metal clips around the edges of a small fenestration result in optimal effects with minimum fenestration size.

METHODS AND ANALYSIS

This trial has been initiated in July 2019 and is expected to last for 2 and a half years. All patients older than 18 years, who receive kidneys from deceased donors, will be included. The kidney recipients will be randomly allocated to either a control arm (small fenestration alone) or an intervention arm (small fenestration with clipping). All fenestrations will be round, maximum 2 cm, and close to the kidney hilum. Clipping will be performed with eight metal clips around the peritoneal window (360°) in every 45° in an oblique position. The primary endpoint is the incidence of symptomatic post-KTx lymphatic complications, which require interventional treatment within 6 months after KTx. Secondary endpoints are intraoperative and postoperative outcomes, including blood loss, operation time, severity grade of lymphocele/lymphorrhea and relative symptoms.

ETHICS AND DISSEMINATION

This protocol study received approval from the Ethics Committee of the University of Heidelberg (Registration Number S-318/2017). A Standard Protocol Items: Recommendations for Interventional Trials checklist is available for this protocol. The results will be disseminated through peer-reviewed journals and conference presentations.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT03682627).

Consensus on definition and severity grading of lymphatic complications after kidney transplantation

BACKGROUND

The incidence of lymphatic complications after kidney transplantation varies considerably in the literature. This is partly because a universally accepted definition has not been established. This study aimed to propose an acceptable definition and severity grading system for lymphatic complications based on their management strategy.

METHODS

Relevant literature published in MEDLINE and Web of Science was searched systematically. A consensus for definition and a severity grading was then sought between 20 high-volume transplant centres.

RESULTS

Lymphorrhoea/lymphocele was defined in 32 of 87 included studies. Sixty-three articles explained how lymphatic complications were managed, but none graded their severity. The proposed definition of lymphorrhoea was leakage of more than 50 ml fluid (not urine, blood or pus) per day from the drain, or the drain site after removal of the drain, for more than 1 week after kidney transplantation. The proposed definition of lymphocele was a fluid collection of any size near to the transplanted kidney, after urinoma, haematoma and abscess have been excluded. Grade A lymphatic complications have a minor and/or non-invasive impact on the clinical management of the patient; grade B complications require non-surgical intervention; and grade C complications require invasive surgical intervention.

CONCLUSION

A clear definition and severity grading for lymphatic complications after kidney transplantation was agreed. The proposed definitions should allow better comparisons between studies.

Surgical Strategies for Lymphocele Prevention in Minimally Invasive Radical Prostatectomy and Lymph Node Dissection: A Systematic Review

Purpose: Pelvic lymph node dissection is an important step during robotic radical prostatectomy. The collection of lymphatic fluid (lymphocele) is the most common complication with potentially severe impact; therefore, different strategies have been proposed to reduce its incidence. Materials and Methods: In this systematic review, EMBASE, MEDLINE, Cochrane Library, and NIH Registry of Clinical Trials were searched for articles including the following interventions: transperitoneal vs extraperitoneal approach, any reconfiguration of the peritoneum, the use of pelvic drains, and the use of different sealing techniques and sealing agents. The outcome evaluated was the incidence of symptomatic lymphocele. Randomized, nonrandomized, and/or retrospective studies were included. Results: Twelve studies were included (including one ongoing randomized clinical trial). Because of heterogeneity of included studies, no meta-analysis was performed. No significant impact was reported by different sealing techniques and agents or by surgical approach. Three retrospective, nonrandomized studies showed a potential benefit of peritoneal reconfiguration to maximize the peritoneal surface of reabsorption. Conclusion: Lymphocele formation is a multistep and multifactorial event; high-quality literature analyzing risk factors and preventive measures is rather scarce. Peritoneal reconfiguration could represent a reasonable option that deserves further evaluation; no other preventive measure is supported by current evidence.

Predictors of symptomatic lymphocele after kidney transplantation

Purpose

The development of a symptomatic lymphocele (SL) is a frequent postoperative surgical complication after kidney transplantation. It may lead to pain and discomfort and cause transplant malfunction or even secondary graft loss. A large cohort of renal recipients was investigated to identify the possible risk factors for SL.

Methods

All renal transplant patients of a single centre were retrospectively analysed for SL between January 2010 and December 2017. The SL group was compared to a control group from the same cohort.

Results

45 out of 1003 transplanted patients developed an SL (incidence 4.5%), on average 50 days after kidney transplantation. SLs developed more in older patients, in those with a PD catheter and in ADKDP as primary diagnosis. Surgical predictors for SLs were venous anastomosis on the external iliac vein, concomitant PD catheter removal, perfusion defects, shorter operating time, splint > 7 days, double J stenting, discharge with drain, low initial drain production and ureteral obstruction. Opening of the peritoneum, re-operation for postoperative bleeding and previous nephrectomy seem protective for developing SL.

Conclusion

We found multiple heterogeneous predictors for SL with a common denominator related to surgical management of the retroperitoneal space, peritoneum and the ureter. Future prospective studies are necessary to evaluate the influence of these variables on the development of SL.