A Large Pleural Effusion in a Patient Receiving Peritoneal Dialysis

Abstract

Hydrothorax as a complication of peritoneal dialysis (PD) is a rare but recognized event. Proposed mechanisms for the development of a pleuro-peritoneal communication include congenital diaphragmatic defects, acquired weakening of diaphragmatic fibers caused by high intra-abdominal pressures during peritoneal dialysis, and impairments in lymphatic drainage. Pleural fluid analysis and diagnostic imaging assist in differentiation from other causes of pleural effusion. Nearly 50% of patients with this diagnosis have resolution of hydrothorax after temporary cessation of PD with interim hemodialysis for 2-6 weeks. Historically, other treatment options have included conventional pleurodesis and open thoracotomy with direct repair, producing variable results. With the advent of video-assisted thoracoscopy (VATS), surgical repairs and pleurodesis are now frequently performed under direct visualization with minimal invasiveness. We report a case of hydrothorax in a patient after recent introduction to peritoneal dialysis. Pleuro-peritoneal communication was documented with thoracentesis and radionuclide scanning. VATS pleurodesis with talc was performed. Repeat scintigraphy performed 1 week after the procedure revealed no residual communication, and patient was able to resume PD without further complications.

Pleuroperitoneal Leak Complicating Continuous Ambulatory Peritoneal Dialysis: A Case Report

“…It is evident that acute hydrothorax can develop in few hours to few years in patients having CAPD [5,8,9]. Pleuro-peritoneal leak secondary to congenital defect usually develops shortly after the initiation of the PD treatment [5,9]. However, like in our case, there are patients presenting with the late development of hydrothorax even in the eighth year of PD treatment [2].…”

“…The fluid passage between the peritoneal and pleural cavity stems usually from the congenital or acute diaphragmatic defects [4,5]. It has been mooted that during the PD treatment, increased intraabdominal pressure can tear the previously intact collagen fibers and eventually leads to leakage [4].…”

“…Krishnan et al [7] identified the frequent development of acute hydrothorax in patients on PD initiated at 40 mL/kg dialysate volume compared to the patient's dialysate volume gradually increased. It is evident that acute hydrothorax can develop in few hours to few years in patients having CAPD [5,8,9]. Pleuro-peritoneal leak secondary to congenital defect usually develops shortly after the initiation of the PD treatment [5,9].…”

Gastrointestinal Non-Infectious Complications in Patients on Peritoneal Dialysis

“…The cut-off value for the diagnosis of pleural effusions caused by peritoneal dialysis is a pleural liquid-serum concentration gradient greater than 2.77 mmol/ l (50 mg/ dl) (15). The treatment of pleural effusion associated with peritoneal dialysis (peritoneal-pleural dialysate leaking) is termination of PD therapy (4-6 weeks after cessation of peritoneal dialysis there is resolution of the effusion), video-assisted thoracoscopic surgery and talc pleurodesis (tetracycline and fibrin gel are equally used for pleurodesis) (16,17,18).…”

Peritoneal dialysis‐related hydrothorax: A conservative approach should be the best beginning option

“…Generally, a conservative treatment precedes all invasive intervention . Nearly, 50% of patients have resolution of hydrothorax after temporary cessation of PD with interim haemodialysis for 2–6 weeks . Chemical pleurodesis, with a failure‐rate approximately 50%, and open or laparoscopic surgery are other common therapies .…”