Large-volume sirolimus-induced upper limb lymphedema after renal transplantation ipsilateral to the arteriovenous fistula.

Objective: To analyze upper-limb lymphedema characteristics of renal transplant recipients taking sirolimus, an mTOR inhibitor. Method: Cross-sectional study of sirolimus-treated upper-limb lymphedema patients (01/2009-12/2013). Results: Three men and two women, whose mean age at transplantation was 60 (range: 49-76) years, were included. Sirolimus (1-2.5 mg/day) had been taken for 27.5 +/- 21 (range: 7-58) months before left (n = 4) or right (n = 1), whole limb (n = 4), or hand and forearm (n = 1) upper-limb lymphedema onset, always ipsilateral to the functional arteriovenous fistula. Ultrasonography or fistulography excluded venous thrombosis in all patients. At the time lymphedema appeared, all five arteriovenous fistulas were functional. Mean upper-limb lymphedema volume, calculated with the truncated-cone formula, was 774 +/- 162 [range: 594-1035] mL, (i.e. 44%+/- 11% [range: 36%-64%] excess volume compared to the contralateral limb. One patient also had ipsilateral breast lymphedema. The three lymphoscintigraphies obtained showed total absence of ipsilateral axillary-region tracer uptake. Sirolimus was maintained in all cases. Upper-limb lymphedema treatment included low-stretch bandages (n = 4) and elastic sleeve (20-36mm Hg) (n = 5) without fistula complications. Two patients had their fistulas closed without any impact on lymphedema volume. Conclusion: Sirolimus may be implicated in large-volume upper-limb lymphedema in kidney-transplant recipients, ipsilateral to the arteriovenous fistula, and requires compression-based therapy.