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Fistola linfatica e linfocele

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These large discrepancies were attributed to multiple causes, such as extent of surgical dissection, rejection episodes, use of diuretics, large doses of corticosteroids and anticoagulants (21), but very importantly, most of the studies were retrospective, and the TXL incidence was calculated

on the basis of clinical records. As a consequence, only the symptomatic cases and the casually detected fluid collections were reported.

The frequency of TXL markedly increased when ultrasonography became a routine examination.



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CK is an enzyme expressed in various tissues and cell types but predominantly in striated muscle.

CK catalyzes the reversible conversion of creatine and adenosine triphosphate (ATP) to phosphocreatine

and adenosine diphosphate (ADP)

Due to its high muscle specificity CK activity was used as a marker of iliac lymph



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Group C

Standard technique: vascular anastomoses on the external iliac vessels;

group M

Cephalad implantation of the graft in the ipsilateral iliac fossa and vascular anastomoses in the common iliac vessels.



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Multiple renal arteries are unilaterally found in 25% of the population and bilaterally in 10%

Usually the lymphatic vessels are more abundant in grafts with multiple arteries and so they are vulnerable to insufficient ligature, therefore, speculate that this fact can explain the higher occurrence of lymphocele among grafts with multiple arteries



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1700 patients received kidneys from live donation, and 9 patients received from cadaver donor



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Renal cortex

In the interstitium between the tubules, lymphatic capillaries exhibited a tubular shape or a slit-like structure and were scarce near blood capillaries.

Similar lymphatic capillaries were observed sporadically in the interstitium around the glomeruli

The interlobular arteries and veins were accompanied by a relatively narrow and fibrous interstitium, in which lymphatic vessels were abundant (Figure 2b). Lymphatics around the interlobular veins were more developed than those around the interlobular arteries

Renal medulla

Lymphatics were extremely rare in the medulla

Lymphatics were abundant in the interstitium around the interlobar arteries and ran alongside them

The arcuate arteries ⁄ veins were also accompanied by lymphatics, whose distribution was similar to that in the interlobar arteries ⁄ veins



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The pattern of the renal lymphatic system suggests that 2 networks exist

The principal one collects lymph from the cortex and the medulla and carries it through the arcuate and interlobar collectors to the hilar lymphatic ducts

The lesser one drains the lymph from the outer cortex to a subcapsular web, and by means of perforating channels in the pericapsular space to the lymphatic vessels of the perirenal fat

In normal conditions, the lymph outflow from the latter is probably very small or negligible.

Renal lymph forward flow is due to the axial pressure gradient along the lymph collectors, aided by 1-way valves which prevent backflow

The interlobar collectors have muscular cells in their walls, capable of both tonic and phasic contractions to promote lymph flow

lymph propulsion in the lymph vessels by active contraction of the vessels, first described by Arnold Heller in 1869



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Only in areas of advanced tissue damage were emboli found inside vessels with grossly damaged endothelium. This progressive

plugging of the renal capillaries with blast cells would lead to profound changes in the hemodynamics in the kidney and could well have been responsible for an increased filtration pressure in the patent capillaries which would account for the increased lymph production.

The Renal Autograft.--The large volume of lymph draining from this transplanted kidney during the early post-operative period made it evident that adequate lymphatic drainage was important in reducing the edema of the kidney that is an inevitable consequence of transplantation

In a study using a sheep model, it was shown that lymph drainage from allografts was 60 mL/hr compared with 3.2 mL/hr from autografts



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The rejection-associated inflammatory state causes a manifold increase of lymph production by the kidney.

The fluid in excess is looking for an alternate outlet because of the tight ligature of hilar lymphatic ducts

The way out can only be the lymphatic vessels of the outer cortex, connected to the subcapsular network and, through perforating channels, to the pericapsular space

It is probable that immediately after intervention the increase in interstitial fluid exerts an external pressure able to compress and close the lymph collecting vessels and to stop both lymph movement and production.

The inflammation caused by clinical or subclinical rejection could alter this equilibrium, by attracting interstitial fluid and further increasing interstitial fluid volume and pressure (62), which in turn induce dilatation and proliferation of new lymphatic vessels (lymphangiogenesis) and prepare the subcapsular network to become a major alternate outlet



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The literature search identified a total of 518 unique references of which 37 RCTs met the inclusion criteria for

the qualitative analysis

Forest plot indicating the odds ratio of the occurrence of lymphoceles in kidney transplant recipients on mTOR inhibitors plus calcineurin inhibitors



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This study shows that the combination of SRL/MMF/P, obesity

(BMI greater than 30 kg/m2) and acute rejection are

independent risk factors for lymphocele formation and treatment.



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Non-symptomatic lymphoceles were treated conservatively, whereas renal allograft recipients with larger and symptomatic lymphoceles underwent percutaneous drainage (lympocele diameter 3–5 cm) or laparoscopic fenestration (diameter>5 cm). Irrespective of the size, infected lymphoceles were drained percutaneously first.

Failure of percutaneous drainage with persistent secretion (>30 mL/24 h) after two wk of treatment led to the laparoscopic approach



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A 69 years old male patient underwent monolateral dual kidney transplantation

However, the US performed in the operative room did not clearly identify a suitable site for a safe drainage insertion,

because of the complex mutual relations among the collection, the renal vessels, and the ureters.

A retrograde cystography using echographic contrast agent was performed



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The lymph formed in the sheep's kidney drains from the hilum through several small lymphatics; there is no lymphatic drainage from the renal capsule

The concentrations of electrolytes and urea in renal lymph were found to be similar to lymph from other regions of the body, but the concentration

of endogenous creatinine was lower. The average concentration of protein in renal lymph was 43 % of the plasma levels; there was a significantly

higher proportion of albumin in renal lymph than in plasma.

The concentration of renin enzyme was on the average about 8 times higher in renal lymph than in jugular vein or renal vein plasma or in

lymph from the hind limbs.



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enoxaparin at the dose of 20 mg x 1 s. c The mean duration of prophylactic treatment was 10.4 days (range 0-47)

One is that anticoagulation therapy influences the ability of blood to clot, thereby impairing the sealing of lymph vessels in the wound.

Secondly, lymph, like plasma, contains coagulation factors (12). Its clotting ability can therefore be affected by anticoagulation therapy.



release  1
pubblicata il  15 marzo 2013 
da A. Ranghino
((Torino, Italia))
Parole chiave: fistola linfatica, linfocele
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