Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2014  |  Volume : 25  |  Issue : 1  |  Page : 105--108

Leak from the surface of a decapsulated renal allograft: Urine or lymph? Excellent response to povidone iodine instillation


Rathore Yashwant1, Sandeep Guleria1, Nikhil Khattar2, Rakesh Kumar3, Surjeet Kumar1,  
1 Department of Surgery, All India Institute of Medical Sciences, New Delhi, India
2 Department of Urology, PGIMER and Dr. Ram Manohar Lohia Hospital, New Delhi, India
3 Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Sandeep Guleria
Department of Surgery, All India Institute of Medical Sciences, New Delhi
India




How to cite this article:
Yashwant R, Guleria S, Khattar N, Kumar R, Kumar S. Leak from the surface of a decapsulated renal allograft: Urine or lymph? Excellent response to povidone iodine instillation.Saudi J Kidney Dis Transpl 2014;25:105-108


How to cite this URL:
Yashwant R, Guleria S, Khattar N, Kumar R, Kumar S. Leak from the surface of a decapsulated renal allograft: Urine or lymph? Excellent response to povidone iodine instillation. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2021 Jul 29 ];25:105-108
Available from: https://www.sjkdt.org/text.asp?2014/25/1/105/124512


Full Text

 Introduction



Capsular injury to the kidney during donor nephrectomy in live related renal transplant is a rare complication. It has been reported in laparoscopic procedures. We report a case where the only suitable kidney available from an otherwise fit donor had a cortical scar and, during open donor nephrectomy, dense adhe­sions led to the kidney being decapsulated. After transplant, the recipient developed pro­longed leakage from the surface of the cortex, and this responded successfully to povidone iodine instillation.

 Case Report



A 37-year-old male with end-stage renal di­sease was referred to us for renal transplan­tation. The only acceptable donor was his father aged 58 years. The donor was non-diabetic and non-hypertensive and had no previous history of urinary symptoms or pyelonephritis. On evaluation, he was found to have two renal arteries on the left side and a single artery on the right side. The right kidney had a scar near its lower pole on computerized tomogram, and the function on the right side was 48%, where­as it was 52% on the left side. He underwent a right open donor nephrectomy. During nephrectomy, the kidney had dense adhesions with the surrounding structures near the scar and, while releasing them, a subcapsular plane was entered inadvertently, and at retrieval the entire kidney was decapsulated [Figure 1].{Figure 1}

The renal transplant was uneventful and the kidney had good primary function. The kidney was wrapped at the time of closure in a vicryl mesh. The ureteroneocystostomy was performed over a double J stent tied to the catheter. Post-operatively, the patient produced 9-10 L of urine throughout along with serial decrease in serum creatinine, but the drain output re­mained 400-500 mL. On the 6 th post-operative day (POD), a diethyl triamine pentaacetic acid (DTPA) scan revealed non-obstructive clea­rance of tracer into the bladder without any leakage. The catheter along with the DJ stent was removed on POD 8. Following this, the drain output increased to 900-950 mL. Drain fluid creatinine was 9.3 mg/dL and 800 mg/24 h on POD 10 when the recipient's serum creatinine was 1.6 mg/dL. A repeat DTPA scan showed a kidney with normal function with non-obstructive clearance into the bladder but a diffuse perinephric tracer collection [Figure 2] originating from the entire surface of the kidney. A diagnosis of a capsular urine leak was made. Subsequently, 30 mL of 5% povidine iodine in alcohol base was instilled daily from the drain and the drain was clamped for 20 min. The drain output gradually reduced by the 30 th day, and was subsequently removed. The patient was discharged with a normal ultrasound and a serum creatinine of 1.2 mg/ dL.{Figure 2}

 Discussion



Decapsulation of the kidney during donor nephrectomy has been observed rarely in laparoscopic procedures, mainly during retrieval of the kidney using an entrapment device. [1] De­capsulation leading to a diffuse capsular urine leak has been described only once earlier for laparoscopic donor nephrectomy. [2],[3] However, decapsulation has been noted to occur as a late complication either spontaneously [4] or due to immunosuppression-related complications, especially in patients on sirolimus. [5]

The nature of fluid leaking after decapsulation of a kidney is a controversial issue. Mousson et al in 1998 [4] reviewed the nature of fluid collected after spontaneous renal allograft decapsulation. They argued that although the biochemical composition including sodium, potassium, cholesterol, protein and creatinine of the fluid did not differ much from that of lymph, but late occurrence (4-7 years after transplantation), subcapsular location and large volumes of the fluid did not agree with a lymphocele occurrence. They also pointed out that in the case of Ngheim et al, [6] a Tc 99-labeled sulfur colloid lymphangiogram of the foot failed to reveal any leakage in the perigraft region of a patient with collection after spontaneous decapsulation. Thus, they conclu­ded the nature of such collection to be a transudate leaking from the renal cortical surface.

In contrast, in the two cases reported with intraoperative degloving, including our case, the fluid had higher creatinine than serum (2.0 and 0.9 mg/dL in Mekeel et al's report and 9.0 and 1.6 mg/dL for our case). Moreover, DTPA scans demonstrated leakage of tracer in the perirenal area, indicating the nature of the fluid to be like urine in all likelihood.

The physiological basis of urine secretion from the decapsulated cortical surface is not clear, as is the fact that the same decapsulation later in the course after transplantation leaks transudate rather than urine. A few reports have addressed the effects of decapsulation on the renal function. Decapsulation in a post-ischemic kidney was proposed to avoid compart­ment syndrome of kidney and anuria in pa­tients recovering from shock, as it was shown to increase the blood flow to the renal cortex [7] but was later condemned in further experi­mental studies. [8] It is possible that increased cortical flow, volume expansion in the imme­diate post-operative period leading to high renal interstitial pressures and high ureteral pressures due to immense urine production and a relative obstruction in the immediate post­operative period lead to some back diffusion of urine through the decapsulated kidney. Fur­ther experimental animal studies are required to address this issue.

Because the number of cases reported in the literature is small, there is no unanimity on the management. Mekeel et al re-explored the pa­tient at one month and wrapped the kidney in cellulose membrane and sealed it with fibrin glue along with making a peritoneal window to drain the excess fluid. [2] Roarke and Neguyen have indicated that ureteral stenting will be of little use as the leakage is from the kidney surface. [3] We believe that high ureteral pres­sures in the immediate post-operative period have a role in back diffusion of some urine through the kidney surface, and this is the reason why creatinine of the oozing fluid is higher than in the reported cases of late spon­taneous decapsulation. Thus, we had contem­plated antegrade stenting for our case but were cautious given the already decapsulated and fragile parenchyma. This would have remained our next line of treatment had the drainage not shown a decreasing trend.

The drainage can be irritatingly prolonged and has led to resorting to graft nephrectomy in two of the five cases, [9] and re-explorations in others. Marsupialization into the peritoneal window, [6] infrared contact coagulation of the allograft surface [10] and wrapping in cellulose membrane with fibrin glue application as sta­ted above have helped achieve success and graft salvage. Instillation of a sclerosing agent like povidine iodine for the management of lymphoceles after transplant has been men­tioned by Guleria et al, [11] and we also used the same with successful results. In conclusion, although the exact nature of this fluid is unclear, povidine iodine instillations can be used as an alternate to decrease leakage before resorting to re-exploration.

References

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