D181 - A Case Report: Recurrent Herniation of Kidney Allograft Through Incisional Hernia

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Author Block: S. Goel, M. Doshi, S. Norman, R. Parasuraman, Internal Medicine, University of Michigan, Ann Arbor, MI
*Purpose: Introduction: The incidence of incisional hernia (IH) following kidney transplantation (KT) is reported to be 1.1% to 7.0% (mean 3.2%). Although many cases of transplant ureteral and bladder herniation have been reported, kidney allograft herniation through an IH is extremely rare. We report a case of recurrent allograft herniation through IH to emphasize the need for mitigation of risk factors to avoid such complications.
*Methods: Case report: A 51-year-old obese patient (BMI 36.4 kg/m², abdominal girth 49 in.) with ESKD secondary to ADPKD was on hemodialysis for 12 years prior to receiving a deceased donor kidney transplant (DDKT). He received rabbit anti-thymocyte globulin and standard triple immunosuppression (IS), and had immediate graft function. Two weeks post-KT, he developed wound dehiscence and a large lymphocele (19 x 12 cm) with IH. This required surgical drainage and hernia repair with mesh placement (Fig. 1). He later developed a recurrent lymphocele with Candida infection and recurrent IH with allograft herniation (Fig. 2), requiring aspirations and six-months of antifungal therapy. One year post-KT, he underwent a simultaneous laparoscopic hand-assisted bilateral native nephrectomy (each kidney weighing > 1 kg) and IH repair with mesh, which required a prolonged hospitalization.
*Results: IH is associated with significant morbidity, impacting patient quality of life, activities of daily living, mobility, occupation, and psychological well-being. Potential risk factors for IH include: female sex, age >50 years, history of smoking, diabetes mellitus, pulmonary disease, long duration of dialysis, obesity (BMI > 30 kg/m²), ADPKD, DDKT, longer KT surgery, multiple explorations of the ipsilateral iliac fossa, delayed graft function, post-operative lymphocele, wound infection, and defective wound healing from IS. ADPKD patients with very large kidneys are five times more likely to develop IH with a prevalence rate up to 45%. A simultaneous unilateral native nephrectomy during the KT surgery is a recognized preventative approach for IH in this population. Further mitigation strategies include adequate ligation of both the recipient's perivascular lymphatic vessels and the donor kidney's hilar lymphatics to decrease the risk of lymphocele formation.
*Conclusions: Kidney allograft herniation through IH is a rare, yet a significant morbidity in KT patients, as demonstrated by our case. It is critical to mitigate the major risk factors for IH. In ADPKD patients with large kidneys, a pre-transplant or simultaneous native nephrectomy with KT surgery can decrease the risk of these complications.