Donor workup in renal transplantation is extensive with the aim of ensuring donor safety at all costs and at the same time providing an adequately functioning kidney to the recipient. However, complications may occur. One of them, although rare, is postoperative chyle leak.
We reviewed our experience of 684 living renal donors since 1991 to date. They had undergone standard open retroperitoneal donor nephrectomy after complete preoperative workup. At the time of closure, a drain was placed in the renal fossa which was removed when the drainage became less than 50 mL/day. We encountered chyle leak in two cases.
A 33-year-old female, resident of nonfilaria endemic area, was a voluntary kidney donor for her husband. She underwent an otherwise uneventful left retroperitoneal donor nephrectomy. After an initial fall, drain output started to increase and became milky after postoperative day 3, after commencement of oral feeds (Figure
Daily postoperative drain output of Patient number 1.
She was managed aggressively and was started on TPN for a week. Drain output reduced, and subsequently oral feeds were restarted comprising of high-protein, low-fat (mainly medium-chain triglyceride) diet. Leak gradually subsided spontaneously in total of three weeks, and at that time the drain was removed (Figure
Case number 1 with retroperitoneal drain in situ.
A 42-year-old female was with a similar case history as the first case. She also had undergone left open donor nephrectomy with an uneventful intraoperative period. She had milky fluid in drain after start of oral diet (max output: (200/day)). This patient was also managed conservatively with dietary management. Leak gradually subsided spontaneously in 7 days (Figure
Case number 2 with retroperitoneal drain in situ.
Both patients remained symptom-free on followup. Incidentally, the recipients of both kidneys did well.
After reviewing the literature for this complication, we found that we are first to report two cases of chyle leak following open donor nephrectomy. However, there are few reports of chylous ascites following laparoscopic donor nephrectomy (Table
Author | Year published/laparoscopic (LDN) or open donor nephrectomy (ODN) | Pts ( |
Number of Pts with chylous ascites/leak in drain |
---|---|---|---|
Shafizadeh et al. [ |
2002/LDN | Case report | 1 |
Molina et al. [ |
2003/LDN | Case report | 1 |
Geary et al. [ |
2004/LDN | Case report | 1 |
Leventhal et al. [ |
2004/LDN | 500 | 2 |
Wu et al. [ |
2004/LDN | 10 | 1 |
Ramani et al. [ |
2005/LDN | 79 | 1 |
Caumartin et al. [ |
2005/LDN | Case report | 1 |
Sharma et al. [ |
2005/LDN | Case report | 1 |
Breda et al., 2006 [ |
2006/LDN | 300 | 2 |
Bachmann et al. [ |
2008/LDN | 164 | 3 |
Wadstrom J. [ |
2005/hand-assisted LDN | 75 | 1 |
Aerts et al., 2009 [ |
2009/LDN | 1054 | 3 |
Most reports listed the complication occurring after left laparoscopic donor nephrectomy. In our study also, both the cases had undergone left donor nephrectomy. The cause for this finding is not known. It may be incidental as the frequency of left donor nephrectomy is much greater than right donor nephrectomy or this complication is unique to left side. Further inquiries and investigative efforts are needed in this regard.
Chyle leak has been reported after other abdominal surgeries also. Abdominal surgical procedures usually causing chyle leak include Abdominal aortic aneurysm repair (80% of all postsurgical chylous ascites), Retro-peritoneal lymph node dissection, Inferior vena caval resection & Liver transplant [
The cause of chyle leak following donor nephrectomy is not exactly known. Chyle leak has been increasingly reported in the recent past, indicating the possible role of inadequate control of perivascular lymphatics during nephrectomy performed by minimally invasive techniques where energy sources like harmonic, LigaSure, and electrocautery are used. These modalities may not be as effective in control of lymphatics as suture ligation or clipping as suggested by Nishizawa et al. with respect to chylous ascites following laparoscopic radical nephrectomy [
Treatment options in patients with postoperative chylous ascites primarily involve conservative management in the form of dietary modifications. Constant loss of protein and lymphocytes may cause nutritional and immunological disturbances. The major bulk of fat in diet should comprise of free fatty acids and medium chain triglycerides as these are absorbed directly from the gut into the portal venous circulation. Total parenteral nutrition (TPN) is required in cases who do not respond to dietary modifications. Essential fatty acids and fat soluble vitamins need to be supplemented. Somatostatin has been shown to be effective in one study [
Chyle leak following donor nephrectomy may be prevented by meticulous surgical dissection and clipping/ligating all the lymphatic tissue around the renal vessels. It can be managed with conservative treatment in most of the cases.
Informed consent was obtained from the patients.