Abstract: PO2224
Sirolimus and Chyloperitoneum: A Rare Pair
Session Information
- Transplantation: Clinical - Noninvasive Biomarkers, Immune Regulation, and Fascinomas
November 04, 2021 | Location: On-Demand, Virtual Only
Abstract Time: 10:00 AM - 12:00 PM
Category: Transplantation
- 1902 Transplantation: Clinical
Authors
- Rodriguez, Juanly N., University of Miami School of Medicine, Miami, Florida, United States
- Seneriz, Ramon A., University of Miami School of Medicine, Miami, Florida, United States
- Dejman, Adriana, University of Miami School of Medicine, Miami, Florida, United States
Introduction
The mammalian target of rapamycin inhibitors (mTORi) are associated with complications like hyperlipidemia, lymphoceles, lymphedema and rarely chylous ascites (CA), characterized by a milky colored, triglyceride (TG) rich fluid leading to dehydration, electrolytes imbalances and immunosuppression. We present a case of sirolimus induced chyloperitoneum in an ESKD patient.
Case Description
44 year old woman with heart failure reduced ejection fraction (HFrEF) secondary to transposition of great vessels and orthotropic heart transplant in 2007, NASH cirrhosis and ESKD from calcineurin inhibitor toxicity, switched to sirolimus in 2018. Renal function declined requiring initiation of peritoneal dialysis (PD) in December 2020. 3 months prior patient presented with right upper extremity (RUE)/ipsilateral breast swelling, erythema and dull pain. US doppler ruled out DVT. Lymphangitis/cellulitis was suspected, started antibiotics with some improvement. Lymphoscintigram showed diffuse skin/right breast soft tissue edema. PD catheter was placed, incidentally found mild clear ascites, liver cirrhosis and bilateral ovarian cysts, work up for malignancy was negative and discharged. She trained for PD and effluent for KT/V had milky appearance. Fluid anlaysis showed nucleated cell count 1151mcL, RBCs 1391mcL, total protein 2.4g/dl, albumin 1g/dL, amylase <30u/L, glucose 160mg/dL, LDH 248IU and TG level 141mg/dl consistent with CA. Sirolimus was held and 2 weeks after PD fluid cleared and RUE lymphedema slowly improved with right breast enlargement to date.
Discussion
CA results from disruptive lymphatic system and posterior leakage of lymph into the abdominal cavity. Diagnosis requires TG levels >110mg/dl and gold standard imaging test is lymphangiography. Multiple etiologies are proposed: malignancy, traumatic surgical injury, liver cirrhosis and cardiovascular disease. Less common, mycobacterium infections and medications (mTORi, calcium channel blockers). Sirolimus causes disruption in proliferative signals required to seal perivascular lymphatics leading to high rates of lymphedema/lymphoceles. This explains RUE/ipsilateral breast swelling in our case. As the PD fluid cleared after stopping the sirolimus, it was deemed the cause. Cornerstone of therapy is correcting underlying cause. Presence of CA warrants immediate attention and targeting underlying cause, crucial for rapid recovery and avoiding complications.