Percutaneous Management of Lymphoceles after Renal Transplantation

Chronic kidney disease (CKD) is a worldwide public health problem. In the United States, between 1988–1994 and 2005–2010, the overall prevalence estimate for CKD, defined by an estimation of glomerular filtration rate <60 ml/min per 1.73m² or a urine albumin-to-creatinine ratio ≥30 mg/g, rose from 12.3 to 14.0%. In 2010, overall per person per year costs for patients with CKD reached $22,323 for Medicare patients ≥65 years and older, and the overall Medicare expenditure for CKD was $41.0 billion, which consisted of 17% of the total Medicare dollars allocated.[1]

Kidney transplantation is the treatment of choice for patients with end-stage renal disease and should be discussed with patients with advanced CKD preparing for renal replacement therapy.[2] The annual number of kidney transplants in the United States extends beyond 17,000 patients (deceased donors to living donors), and potential candidates should be referred promptly to a transplant center. Graft dysfunction arising after renal transplant can be divided into urologic (urine leaks or obstruction), vascular, perirenal fluid collections, and infectious complications. Perirenal transplant fluid collections can develop in the immediate postoperative period or over several months. The differential diagnosis of a perirenal fluid collection immediately after surgery includes seroma, hematoma, and urinoma, and fluid collections that develop in a subacute fashion include abscess or lymphoceles.

Lymphoceles are a common and well-documented complication in renal transplant recipients, occurring in up to 26% of patients.[3] Usually they are found incidentally on routine ultrasonography and require no additional management; however, a small number are symptomatic due to mass effect and require further definitive treatment. Treatment options include laparoscopic/open surgical or percutaneous therapies with each having different profiles of efficacy and complications. At my institution, we commonly use less invasive percutaneous therapies initially, with surgical management reserved for percutaneous treatment failure. Potential current options for the interventional radiologist include simple aspiration, catheter drainage, and sclerotherapy. In a recent systematic review of 52 retrospective case series (1113 cases of primary lymphocele), treatment efficacy was evaluated and demonstrated recurrence rates of 59% (141 cases; n = 218), 50% (100 cases; n = 195), and 31% (41 cases; n = 155) with aspiration, catheter drainage, and sclerotherapy, respectively.[4]

• References

• 1 United States Renal Data System. USRDS 2012 Annual Data Report: Atlas of Chronic Kidney Disease and End-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2012. Available at: www.usrds.org . Accessed on March 28, 2013
• 2 Bunnapradist S, Danovitch GM. Evaluation of adult kidney transplant candidates. Am J Kidney Dis 2007; 50 (5) 890-898
• 3 Atray NK, Moore F, Zaman F , et al. Post transplant lymphocele: a single centre experience. Clin Transplant 2004; 18 (Suppl. 12) 46-49
• 4 Lucewicz A, Wong G, Lam VW , et al. Management of primary symptomatic lymphocele after kidney transplantation: a systematic review. Transplantation 2011; 92 (6) 663-673