William S. Kiser

Lymphoceles associated with renal transplantation: Report of 15 cases and review of the literature

Abstract Within a 27 month period (from July 1, 1971 to October 1, 1973), during which 83 renal allotransplantations were performed at the Cleveland Clinic, a lymphocele developed in 15 patients (18.1 per cent). Early clinical symptoms, occurring within 6 weeks after transplantation, were suprapubic or lower abdominal swelling in 14 patients, leg swelling ipsilateral to the allograft in 12, nonpitting edema in the allograft area in 10 and lymph drainage from the wound in 8. An intravenous pyelogram demonstrated a lymphocele in 13 patients from 1 to 34 weeks after transplantation (mean 7.8 weeks), although an earlier suggestion of bladder displacement and deformity was found retrospectively in 5 patients between 1 and 3 weeks after transplantation. Lymphangiograms aided in the diagnosis in nine patients. The major complication of the lymphoceles was obstructive uropathy that developed in nine patients between 2 and 34 weeks after transplantation (mean 10.3 weeks). Lymphoceles mimicked rejection, urine extravasation, pyelonephritis, thrombophlebitis and a seroma, and occurred concurrently with rejection and pyelonephritis. Treatment by external surgical drainage was more effective than aspiration both in resolving the lymphocele and in avoiding infection. Three lymphoceles drained spontaneously 1 to 2 weeks after transplantation, and three are under observation. Chemical and protein analyses were made of the lymphocele fluid obtained from seven patients. Numerous factors may contribute to the formation of a lymphocele by increasing lymph flow. The most prominent factors are the extent of surgical dissection, the occurrence of rejection, and the use of diuretics, large doses of corticosteroids, and anticoagulants. The literature on lymphoceles in renal allograft recipients is reviewed, and pertinent comparisons are made with the more numerous reports of lymphoceles in nontransplant patients.

A controlled randomized double-blind study of antilymphoblast globulin in cadaver renal transplantation.

Herein are presented the results of a controlled prospective randomized double-blind evaluation of antilymphoblast globulin as an immunosuppressive adjunct to azathioprine and prednisone in cadaver renal transplantation. There were 31 patients and 36 patients randomly assigned to therapeutic and control groups, respectively. ALG-treated patients experienced no major side-effects, a delayed onset of rejection following transplantation (P <.005), a reduced total number of rejection episodes (P <.05), fewer days in the hospital (P < .05), a reduced cost of transplantation (P < .02), improved graft survival (P <.05), and patient survival equivalent to that of the control group. These data indicate that ALG is safe, costeffective, and of immunologic benefit in cadaver renal transplantation.

The Surgical Complications of Renal Transplantation

The complications related to renal transplant surgery are important causes of autograft failure and patient mortality. Complications observed by the authors as well as others were related to preparation of the iliac fossa for implantation of the kidney, and to the methods used for vascular anastomoses or reconstitution of the urinary tract.

SULFADIMETHOXINE IN URINARY TRACT INFECTIONS

Infections of the urinary tract are among the most common seen in man, being exceeded only by those of the respiratory system. A rational approach to therapy in these infections must begin with recognition of the causative microorganism and the conditions favoring its growth in the urinary tract.2 Cook3 emphasizes the importance of determining whether the therapeutic agent is being used to combat infection in an uncomplicated situation or in the presence of stone, tumor, or other obstructive factors contributing to urinary stasis. 85 to 90 per cent of bacteria implicated in urinary infections are controllable with 1 or more members of the sulfonamide group. I n addition to marked effectiveness against Gram-negative and Gram-positive primary invaders, sulfonamides offer ease of administration, an outstanding propensity for maintaining adequate therapeutic levels, a low percentage of complications, and relatively low cost. In this study a new low-dosage long-acting sulfonamide, sulfadimethoxine, was evaluated in terms of effectiveness in controlling infections associated with a variety of urological disorders. The pharmacological properties of this sulfonamide that recommended its consideration were low-dose effectiveness and long-acting potential. Brandman et aL6 have demonstrated therapeutic plasma levels (6 mg. per cent) 4 hours after oral administration of 1 gm., with therapeutically active blood levels maintained 2 1 hours or more. According to Flippin and others4