NDT Advance Access originally published online on July 5, 2006
Nephrology Dialysis Transplantation 2006 21(11):3336-3337; doi:10.1093/ndt/gfl354
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Chylous ascites after renal transplantation — a case report
Email: sjhwang{at}kmu.edu.twSir,
Chylous ascites following renal transplantation is a rare complication that can cause nutritional and immunological problems, especially in the immunocompromised patient [1]. There has been only one case previously reported in the literature [2]. We report here a 54-year-old male who developed chylous ascites 27 days after a successful renal transplantation. The aetiology was apparently either the unrecognized interruption of the lymphatic channels and the leakage of chyle through a lymphoperitoneal fistula [3] or the fenestration of post-transplant lymphoceles to the peritoneum [4]. Thus, this case is quite different from the first report, in which extraordinary surgical manipulation to the abdominal aorta appeared to be the cause [2].
The patient underwent cadaver renal transplantation at the right iliac fossa in August 2004 after 10 years of haemodialysis therapy for end-stage renal failure secondary to diabetes mellitus and hypertension. The operation was uneventful and the kidney functioned well. The serum creatinine declined from 14.5 mg/dl pre-operatively to 1.36 mg/dl on day 22 post-transplantation. The patient received immunosuppressive therapy with prednisolone, tacrolimus and mycophenolate mofetil. Twenty-seven days after transplantation, the patient presented to our emergency department with general oedema and abdominal distension. The serum creatinine concentration was 1.4 mg/dl, and the ultrasound scan of the abdomen showed a large amount of ascites. Diagnostic paracentesis was performed and 2 l of fluid were drained. The ascitic fluid was milky in gross appearance with the triglycerides content at 188.2 mg/dl, which was compatible with chyle [5]. The other biochemical analysis revealed cell count at 90 WBCs/mm3 with all lymphocytes and was sterile for aerobic, anaerobic and tuberculous cultures. The creatinine concentration of ascites was 1.61 mg/dl, vs a urinary creatinine concentration of 20.6 mg/dl, which excludes the possibility of the fluid being of urinary origin. The lymphoscintigraphy revealed transient flush of lymphatic flow in the right lower quadrant area, abnormality of lymphatic circulation and disturbance in the lower abdomen. An abdominal magnetic resaonance imaging (MRI) on day 9 after the diagnosis of chyloperitoneum showed neither enlarged lymph node nor abnormal peritoneal fluid collection, although there was localized fluid over the anterior aspect of the transplanted kidney, which was suspected to be a lymphocele. Dietary intervention with high protein, low fat and medium-chain triglyceride was implemented and maintained for 2 months, and the patient's symptoms did not worsen. A repeat abdominal ultrasonographic examination revealed the disappearance of lymphocele on day 65 post-transplantation. During the 15 months follow-up, the patient was free from ascites and the transplanted kidney worked well.
Post-operative chylous ascites is a rare complication that is caused either by surgical interruption of lymphatic channels or by the fenestration of lymphoceles to the peritoneum. The diagnostic tools are limited to prevent further graft damage by nephrotoxic contrast. Lymphoscintigraphy and 3D MRI may be helpful in demonstrating abnormality of lymph vasculature, especially in renal transplantation. Dietary intervention, during and after chyloperitoneum, is recommended according to our experience. The rapid recovery of chylous ascites may mean that the injury to the lymphatic system is less severe in transplanted procedure.
Conflict of interest statement. None declared.
Department of Nephrology and Urology
Chung-Ho Memorial Hospital
Kaohsiung Medical University
Kaohsiung, Taiwan
References
- Aalami OO, Allen DB, Organ CH Jr. (2000) Chylous ascites: a collective review. Surgery 128:761–778.[CrossRef][Web of Science][Medline]
- Itoh K, Tanda K, Kato C, Kanagawa K, Seki T. (1994) Intraperitoneal leakage of technetium-99m-DTPA following renal transplantation: a sign of chylous ascites. J Nucl Med 35:93–94.
[Abstract/Free Full Text] - Leibovitch I, Mor Y, Golomb J, Ramon J. (2002) The diagnosis and management of postoperative chylous ascites. J Urol 167:449–457.[CrossRef][Web of Science][Medline]
- Seo Y, Shuke N, Yamamoto W, Usui K, Aburano T. (1999) Ruptured lymphocele as a cause of chylous ascites: demonstration by lymphoscintigraphy. Clin Nucl Med 24:60–61.[CrossRef][Web of Science][Medline]
- Cardenas A and Chopra S. (2002) Chylous ascites. Am J Gastroenterol 97:1896–1900.[Web of Science][Medline]
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