Drainage of the Thoracic Lymph Duct During Homologous Kidney Transplantation in Man

Indications, techniques, and clinical outcomes of thoracic duct interventions in patients: a forgotten literature?

BACKGROUND

The evolution of the "gut-lymph concept" has promoted thoracic duct (TD) lymph drainage as a possible treatment to reduce systemic inflammation and end-organ dysfunction in acute illness. The aim was to review the published experience of thoracic duct interventions (TDIs) aimed at improving clinical outcomes.

METHODS

A search of three databases (MEDLINE, EMBASE, and EMBASE CLASSIC) over the last 60 y. The indications for intervention, the technique, and clinical outcomes were reviewed.

RESULTS

There were a wide range of indications for TDI. These included reducing rejection after transplantation, treating inflammatory diseases, and reducing chronic failure of the liver, kidney, and heart. The techniques included TD cannulation and lymphovenuous fistula. The outcomes were variable and often equivocal, and this appears to reflect poor design quality. There is clinical equipoise regarding a therapeutic role of (TD lymph drainage in acute pancreatitis, and probably other acute diseases.

CONCLUSIONS

Until well-designed clinical trials are undertaken, the clinical benefits of TDIs will remain promising, but uncertain.

Individuality: the barrier to optimal immunosuppression

Immunosuppressive therapy aims to protect transplanted organs from host responses. Individuals have unique repertoires of responses to foreign antigens and toxic reactions to immunosuppressants; the former determining the type or intensity of rejection reactions and the latter influencing the severity of iatrogenic effects. Because existing agents target molecules that are widely distributed in tissues, new strategies must selectively block lymphoid cells only, disrupt alloresponses but not innate immune responses, interact synergistically with other agents, facilitate the homeostatic process that naturally leads to graft acceptance and ideally only interrupt donor-specific responses. Approaches presently under investigation aim to alter cell trafficking, or selectively deviate the maturation of antigen-presenting cells or inhibit lymphocyte-activation cascades - events that are crucial to rejection responses.

Architectural alteration of lymphatic tissue produced by extracorporeal thoracic duct filtration

Removal of recirculating lymphocytes from the lymph of calves by extracorporeal thoracic duct filtration results in a state of immunounresponsiveness. Accompanying this is histological evidence of lymphocyte depletion from the lymph organs and structures of the body. Lymph nodes, spleen, hemolymph nodes, Peyer's patches, and thymus appear depleted of the recirculating small lymphocyte. We find this closed model of lymphocyte depletion effective and free of seyere problems with infections and physiological alterations as experienced in mechanical removal, extracorporeal irradiation, and open thoracic duct fistulas.