2. Case presentation.
 57 yrs old Female,Hypertensive , CKD stage V HD on
twice weekly HD since 6 years
 Underwent - LIVE DONOR RELATED TRANSPLANT
(DONOR - BROTHER) on 20/12/13.
 Intraoperatively kidney turned blue in patches post
anastomosis and was pink post papaverin injection.
 WIT= 4 mins. CIT = 1 hour 15 mins.

3. Case presentation.
 DELAYED GRAFT FUNCTION postoperatively as
patient developed ATN (on USG and Doppler, Renal
scan- biopsy was not done)and required lasix infusion
for urine output initially. Patient`s urine output
gradually improved and Sr.creatinine decreased from
6.9 to 2.4 mg/dL from post op day 1 to day 11.

4. Case presentation.
 She had URINARY TRACT INFECTION (ESBL E-coli)
which required Inj.Imipenem + Cilastatin for 10 days.
 PROLONGED ABDOMINAL DRAINAGE -150 ml day
continued till day of discharge ie POST OP Day 25.
Measures like tab DEC, AKT was tried for reducing the
drain output. Urine leak, Chyle was ruled out and drain
fluid was sterile on cultures.
 Patient was discharged with Drain and DJ stent in situ
with Sr.Creatinine decreased to 1.4 mg/dL on post operative
day 25.On Discharge – Triple immunosupression, INH,
ETB, DEC and Tab Ceftum was given

5. Case presentation.
 Meanwhile she followed in OPD. Drain Catheter
manipulation .Found to have NODAT on follow up and
started on insulin.
 Patient got readmitted on 8/2 /2014 with fever, loose
motions , severe dysuria and poor oral intake.
 Investigations on admission showed a creatinine of 2.2 mg
%, Sodium -122 without leucocytosis. Drain fluid was
turbid on examination and Gram stain showed Gram
Negative Bacteria. Urine showed > 200 PC. Drain fluid and
Urine C/S was sent. Patient was started on inj Meropenem
I gm q8h. Drain fluid culture and urine C/S grew
kleibsiella sensitive to colistin, tigecycline and amikacin.
(Heavy and scanty growth respectively).

6. Case presentation.
 Hence Inj Colistin 6 MU followed by 2 MU q8h was
added. She responded symptomatically and turbidity
of the drain fluid decreased. USG showed a
preperitoneal collection of 200 ml with ? tiny
cyst/liquefied abscess at lower pole of the transplanted
kidney. Left Jugular CVP line (Triple lumen) was
inserted on 10/02/2014.Drain fluid gram stain +c/s was
normal on 12/02/2014 and creatinine declined to 1.4
mg % on 13/03/2014

7. Case presentation.
 With subsiding infection, she was posted for
exploration of wound on 14/02/2014 by under GA.
Intraoperative large wound defect with dehiscenced
muscle layer and thick peritoneum noted . The
peritoneum was excised and muscle layer
approximated . Post operatively she was shifted to
SICU and extubated the same day.

10. Case presentation.
 She was later shifted to Wards the next day, and Meropenem and
colistin were continued to day 10. (19/02/2014). Patient though
hemodynamically stable, had severe stomatitis and
odynophagia, and 2-3 episodes of loose motions and abdominal
discomfort. Hence tab. Ciplox 250 mg bdwas started orally
which she did not tolerate and hence tab Levofloxacin was
started 500 mg OD . She had oral candidiasis hence to r/o
esophageal candidiasis her OGD scopy was done on 23/04/2014
which confirmed the same. She was started on Tab Fluconazole
200 mg OD. Dr Amit Desai consult was sought due to major
depression due to the medical illness.Histopathology from OGD
scopy biopsy showed e/o HSV esophagitis and hence Tab
Acyclovir 400 mg q8h was added since 27/02/2014 for 10 days

11. Case presentation.
 Since 18/02/2014 there was a slow rise in serum creatinine
(with good urine output) from 1.8 mg% to 2.5 mg% on 27
/02/2014. Doses of Tacrolimus were adjusted as per the
trough levels. Repeat USG was showing persistent
preperitoneal collection and drain output about 500
ml/day with peri drain leak. Gradual pulling out of the
drain was planned. Repeat Drain fluid and urine cultures
were again showing heavy growth of Kliebsiella pneumonia
and Enterococcus hence injImipenemCilastatin 500 mg
q8h, inj Colistin 2 Mu q12h and tab. Linospan 600 mg q12h
was started . The increment in the creatinine was
attributed to the underlying infection . Kidney biopsy to
rule out a possibility of rejection was not possible due to
ongoing infection.

12. Case presentation.
 Antibiotics were stopped after 14 days with documented
sterile drain fluid and urine c/s on two occasion 3 days
apart. Meanwhile the drain was persistly 500- 800 ml/day
with occasional drop to least 150 ml/day. Patient improved
symptomatically after above. Removal of the drain which
was done on 21/02/2014 and colostomy bag was put. Before
removal drain fluid and urine c/s done again grew
Kliebsiella Pneumonia (Heavy Growth). Hence for
recurrent UTI, Dr OM Srivastava reference was taken who
advised inj Colistin 1 mu OD anjinjsulbactan 500 mg q8h.
which were started on 21/03/2014. Since she had an allergic
reaction to Inj Sulbactam it was changed to injTigecycline
50 mg q12h.

13. Case presentation.
 Progressively the drain output in the colostomy bag
declined and stopped completely on 28/03/2014. There
was collection of the drain fluid in subcutaneous
tissue about 600 ml on USG and decision to aspirate it
was done on 31/03/2014. About 1500 cc of clear fluid
was tapped which was negative for gram stain and
cultures had no growth. The collection wouldn’t stop
from forming and CT scan was done on 4/4/14

18. Case presentation.
Patient underwent Laparoscopic Marsupilisation on
7/4/14.

19. Review of literature.
 Definition: Lymphocele is a pseudocystic entity
with lymph content covered with a hard fi brous
capsule.
 It can be a complication of any surgery
involvingthe lymphatic system.

20. Review of literature.
 Lymphocele occurs 2 weeks to 6 months after
transplantation with its peak incidence being at 6
weeks. On the other hand, its development following
trauma to the kidney and delayed formation 8 years
after transplantation has been reported, too

21. Review of literature.
 The incidence of clinically significant lymphocele is
about 20%, but it may develop in 12% to 40% of
transplant recipients.(3,4) Since the introduction of
ultrasonography, in about half of transplanted
kidneys, collections smaller than 50 cm3 can be
detected, most of which are less than 3 cm in diameter
and resolve spontaneously. Most of the lymphatic
collections are subclinical.

22. Review of literature.
 Etiology:
 Radioisotope studies suggest that most lymphoceles
originate from leakage of lymph from unligated iliac vessel
lymphatics of the recipient.
 Lymphocele can also originate from transplanted kidney
lymphatic vessels.
 In a study by Goel and colleagues, combination of
sirolimus, mycophenolate mofetil, and prednisone was an
independent factor for lymphocele occurrence by a
mechanism of delayed healing of wound and injured
lymphatic vessels.
 obesity (body mass index greater than 30 kg/m2) is an
independent risk factor for lymphocele formation

23. Review of literature.
 Prophylaxis with highmolecular weight heparin can
increase the incidence of lymphocele.
 Lundin and colleagues reported a higher frequency of
lymphocele with heparin prophylaxis (43% versus
20%) in a group of 130 kidney allograft recipients.Such
an increase was not associated with hemorrhagic
events.
 Allograft rejection was most important contributing
factor in lymphocele formation.

24. Review of literature.
 Presentation:
 Most lymphoceles are clinically silent, but the most
common manifestation is impaired graft function in
the presence of perigraft collection and unilateral leg
edema. Many other presentations have been
recognized including:hypertension, pain, fever,
frequency, ipsilateral thrombophlebitis, palpable
mass, and lymphatic fistula.(1) even, a case of urinary
retention due to compressive effect of lymphocele on
the bladder neck has been reported.

25. Treatment:
 Conservative Management. Small asymptomatic
collections are common and usually resolve
spontaneously. Therefore, conservative management
can be satisfactory.

26. Simple Aspiration
Simple Aspiration. Ultrasonography-guided
aspiration is not only diagnostic, but also
therapeutic in selected cases. It can be the initial
treatment modality that allows relief of urinary
obstruction, recovery of kidney function, and
prevention of emergency situation. Although
simple aspiration is sometimes therapeutic, it
may be necessary to perform multiple sessions of
aspiration and the rate of spontaneous recovery
reduces after 3 recurrences. In addition, each
aspiration brings about a low risk of infection.

27. Sclerotherapy.
 Sclerotherapy. Prolonged external drainage via
percutaneous catheter and administration of a
sclerosing agent (instillation) is also used. Recurrences
have been reported in up to 20% of cases following
sclerotherapy. Agents like ethanol, povidone iodine,
and tetracycline have been used for this purpose.

28. Surgery
Surgery for lymphocele is needed in the
presence of local symptoms, graft dysfunction, or
both. Surgical treatment is named incorrectly as
marsupialization, but unroofing or fenestration is
more precise.(1) This therapy is an intraperitoneal
drainage of lymphocele. Because of its
effectiveness and safety, surgery should be the
first line of the treatment.

29. Surgery
 Laparoscopy is the procedure of choice for surgical
management of lymphocele.
 In different series, the rate of recurrence following
laparoscopic marsupialization has been reported
between 5% to 13%, and it has been noted that there is
a risk of injury to other organs.

30. Surgery
In a study on laparoscopic
Lymphocele After Kidney Transplantation—Ebadzadeh and
Tavakkoli - treatment of lymphocele, the mean operative
time was 123 minutes and the mean blood loss
was 43 mL. The authors reported an average
duration of hospitalization of 1.5 days. Only
minor complications were seen. They concluded
that laparoscopy is an effective minimally invasive
treatment and an excellent alternative for open
surgery.
 Hsu TH, Gill IS, Grune MT, et al. Laparoscopiclymphocelectomy: a multi-
institutional analysis. J Urol. 2000;163:1096-8; discussion 8-9

31. Surgery
Open surgery may be required in patients with
a previous abdominal surgery, for lymphoceles
with inappropriate characteristics or location, or
when other simultaneous procedures should be
done. For deep lymphoceles around the lower
pole of the kidney, it seems that open surgery
is safer. In other unusual cases, including thick
wall of lymphocele or bladder rupture during
laparoscopy, open surgery may be necessary.(1)
In a study by Fuller and colleagues, the most
common indication for open drainage was
uninfected wound complication and high
probability of injury to the ureter or the vessels
because of proximity to the hillar structures.

32. Surgery
 In children, prophylactic fenestration between the two
cavities at the end of the operation is recommended by
some authors.
 A new method named intraperitoneal catheter
drainage of lymphocele as an outpatient Procedure
with local anesthesia and Seledinger method.