To review negative pressure wound therapy (NPWT) as an important addition to the conventional methods of wound management.

A systematic review, performed by searching the PubMed, EMBASE and Cochrane Library databases, showed 11 case reports comprising a total of 22 kidney transplantation (KT) patients (range, 1 to 9), who were treated with NPWT. Application of NPWT was associated with successful healing of wounds, leg ulcer, lymphocele and urine leak from ileal conduit.

No complications related to NPWT were reported. However, there was paucity of robust data on the effectiveness of NPWT in KT recipients; therefore, prospective studies assessing its safety and efficacy of NPWT and randomised trials comparing the effectiveness of NPWT with alternative modalities of wound management in KT recipients is recommended.

Negative pressure incision management system, NPWT with instillation and endoscopic vacuum-assisted closure system are in investigational stage.

Kidney transplantation (KT) represents the best treatment modality for patients with end-stage renal disease, providing the best outcomes for survival, quality of life and cost-effectiveness[1]. Immunosuppressive agents administered to prevent rejection and prolong transplant survival, not only increase susceptibility to infections, but also delay wound healing. Post-operative wound infection leading to cavitation and dehiscence continue to remain serious problems resulting in extended hospital stay, readmissions, repeated surgical interventions and protracted recovery, thereby imposing extra cost to the healthcare delivery system[2]. The wound complication rate after KT ranges between 2% to 47%. The risk factors for these complications are advancing age, diabetes mellitus, body mass index, kidney failure, type of surgical incision, re-operation, operator’s experience, and immunosuppressive drugs including sirolimus and steroids[3-6]. The wound-related complications can present as superficial infection, haematomas, lymphocele, and partial or full-thickness wound dehiscence leading to incisional hernias[7].

Negative pressure wound therapy (NPWT), also referred to as, vacuum-assisted closure therapy (VACT), topical negative pressure therapy or microdeformational wound therapy has been evaluated over last two decades and is considered as an useful adjunct to the management of diverse range of lesions including open abdominal wounds, open fractures, post-traumatic wounds, split-thickness skin grafts and after clean surgery in obese patients[8-13]. Application of any new form of treatment in KT patients is associated with concerns on the part of clinicians, particularly when robust evidence supporting their safety and efficacy are lacking. A systematic review of the published literature was carried out to evaluate the effectiveness and safety of NPWT in KT recipients presenting with wound-related complications.

The literature search identified 11 case reports comprising of a total of 22 KT patients (range, 1 to 9) (Table 1), who were treated with NPWT[26-36]. Comparison between NPWT and other methods of wound treatment in KT patients has not been reported in any study.

In 2003, Hodzic et al[32], for the first time, reported successful outcome of application of NPWT for 15 d in 2 KT patients prior to secondary suture of wounds. Successful treatment of an infected and dehisced laparotomy wound following liver and KT in a patient by employing NPWT was reported by Zanus et al[26], where associated complications included acute pancreatitis, abdominal compartment syndrome and wound infection by multi-drug resistant organisms. The patient required 14 successive laparotomies and NPWT for 6 mo for complete closure of the wound[26]. Similarly, Markić et al[34] have described successful treatment with application of NPWT in 2 KT patients who developed infected and dehisced wounds. NPWT was applied for 2 and 3 wk, respectively, which was followed by secondary sutures[34].

The occurrence of ureteric complications significantly delays the recovery following KT and the incidence of such complication ranges between 1.2% and 8.9%[37]. Urinary leak rate of 11% requiring re-implantation was reported by Surange et al[38] in a series of KT into ileal conduits. Two cases of urine leak and wound dehiscence following KT into ileal conduits were managed successfully by Heap et al[28] with the application of NPWT. Secondary suture of the wounds was carried out after two and three months in these patients. The renal function was restored in both patients leading to 141 µmol/L and 75 µmol/L of serum creatinine, respectively, at the end of 3 mo[28]. On the other hand, Ortiz et al[27], had negative experience of NPWT in a KT recipient with peri-renal collection and wound infection. They concluded that NPWT had encouraged and prolonged urine leak, which had healed after 5 d of discontinuation of NPWT[27]. Iesari et al[36] had applied VAC device in a KT patient who had developed spontaneous rupture of urinary bladder due to gangrenous cystitis and extensive wound dehiscence associated with multidrug resistant Acinetobacter baumanni infection. There was significant urine leak following VAC therapy, hence this was discontinued and topical homologous platelet-rich gel was used resulting in complete wound healing[36].

Infection caused by virulent organisms after skin grafts and reconstructive surgery in KT recipients not only lead to failure of treatment, but also can be life-threatening. Thodis et al[29] treated soft tissue infection caused by Vibrio vulnificus with NPWT, which involved the leg in a KT recipient. Autologous platelet concentrate spray further enhanced granulation tissue formation leading to complete epithelialization of the wound after 4 wk[29]. In a similar situation, Devries et al[31] were unsuccessful in treating soft tissue infection on the leg of a KT recipient, that culminated in amputation. As the patient was on sirolimus, wound healing could have been compromised by the same drug[5,31,39].

Lymphocele following KT can cause significant morbidity due to infection and compression of ureter and blood vessels. The reported incidence of lymphocele ranges between 0.6% to 49%[40]. Franchin et al[35] have described successful management of a large deep-seated lymphocele infected with Staphylococcus haemolyticus, Escherichia coli and Enterococcus faecal, with the application of NPWT. Following surgical drainage, the wound had completely dehisced and transplanted kidney exposed. The cavity was packed with foam dressing and device was applied. A negative pressure of 80 mmHg was maintained. The dressing was changed every 5 d. After 45 d, the lymphocele had sealed and skin closed[35].

In a prospective study reported by Shrestha et al[30], 9 KT patients had developed wound infection with cavitation and wound dehiscence. This was associated with significant amount of discharge from the wound, which failed to respond to standard method of treatment. Treatment with NPWT for a median of 9 (range 3-30) d led to cessation of discharge from the wound. Of the 9 patients, 4 patients were managed on an outpatient with portable NPWT device, where the treatment was discontinued after a median of 5.5 (range 3-7) d. The median hospital stay since the employment of NPWT was significantly shorter (5, range 2-12 d) compared to the standard method of treatment prior to application of NPWT (11 d, range, 5-20 d; P = 0.003). The wound healed completely in all 9 cases after the therapy[30].

Recently, Bozkurt et al[33], for the first time, employed Prevena incision management system (Kinetic Concept Inc. San Antonio, Texas, United States) to the clean closed surgical wound for 5 d after a KT and observed complete healing of the wound with no skin or device-related problems.

All infected wounds with associated collections require surgical drainage for early healing. Fleischmann et al[41] from Germany, in 1993, for the first time described the benefit of exposing wounds to sub-atmospheric pressure, which promoted wound debridement and healing. He applied this method in 15 patients with compound fractures and observed enhanced proliferation of the granulation tissue with no associated bone infection leading to complete healing of fractures[41]. In 1997, Louis Argenta and Michael Morykwas introduced NPWT therapy, for the first time, in the treatment of bed sores and slow healing wounds. Since then, NPWT has been extended to treat various types of wounds resulting from surgery, trauma, infection, congenital deformities and tumours[42-44]. The experience of NPWT gained over the past two decades has encouraged clinicians to treat patients globally in both hospital and domiciliary environments[44-46].

This systematic review has confirmed the available evidence on the safety and efficacy of the application of NPWT in KT recipients limited to case reports. On the other hand, the reported experiences do support NPWT in the management of complex wounds following KT, including urine leak from KT in ileal conduits and lymphoceles. The theoretical risk of haemorrhage and urine leak from transmission of suction pressure on the vascular and ureteric anastomoses cannot be ignored. Prolonged urine leak had occurred in two reported cases after KT where NPWT was applied. Discontinuation of NPWT had led to resolution of urine leak. In author’s single KT patient with a urine leak from the ureterovesical junction, treatment with NPWT led to persistence of urine leak for 1 wk. Resolution of the urine leak occurred 2 d after discontinuation of NPWT therapy. Successful outcomes of NPWT in the management of wound infections in cardiac and liver transplant recipients have been described previously[47,48].

Development of enterocutaneous fistula during the course of NPWT is always a concern, which is particularly applicable in in deep wounds after KT, where thin layer of peritoneum lies between the bowel and the foam dressing. Occurrence of enterocutaneous fistula has been observed after NPWT in open abdominal wound. However, the evidence in support of the occurrence of this complication after NPWT is weak[49-51].

Shrestha et al[30], in their largest reported series of 9 patients, observed benefit of NPWT on wound healing, reduced hospital stays and convenience of wound management. The management of 4 patients on an outpatient basis with the NPWT device in situ, was convenient to the patient and saved hospital cost significantly[30].