Scintigraphic peritoneography in the diagnosis of pleuroperitoneal leak complicating peritoneal dialysis

Abstract

A pleuroperitoneal leak (PPL) is a relatively rare complication of peritoneal dialysis (PD) and early diagnosis is essential. Patients suspected of a PPL usually present with dyspnea (marked during inflow of PD fluid) and tend to have transudative high glucose pleural effusions. The PPL scintigraphy (PPLS) is one of the methods for objectively proving a PPL. The effectiveness of PPLS as a noninvasive method of evaluating a suspected PPL and its effectiveness in the exclusion of a leak in patients with similarly presenting comorbidities was assessed. Patients suspected to have a PPL were considered for PPLS based on clinical presentation and pleural fluid analysis. Radiopharmaceutical was administered into the peritoneum via the dialysis port with the patient lying supine and immediate dynamic followed by delayed statics were acquired. Of the 27 scans reviewed, 70% were found to be positive with majority detected within 12 minutes of radiopharmaceutical administration with a high predominance occurring in the right chest ( P < .001). In PPLS-positive patients, when both chest X-rays and planar agreed on showing the right-sided chest predominance, the highest measurements of the pleural glucose:serum glucose ratio were recorded. A statistically significant correlation between the outcome of the scan and final decision on patient management was noted ( P < .01). The PPLS is an effective diagnostic tool for assessing PPLS. However, multicenter studies investigating its added value over other conventional methods are needed to establish it as a highly relevant diagnostic tool.

Delayed pleuroperitoneal leak in an otherwise uncomplicated course of peritoneal dialysis

“…Definitive diagnosis of pleuroperitoneal leaks often relies on both biochemical and radiological assessment 4 . While some propose a PF to serum glucose gradient of at least 2.8 mmol/L is highly suggestive (not satisfied in this case), others postulate any PF to serum glucose ratio >1.0 is suggestive 1–3 . Analysis with peritoneal scintigraphy carries a sensitivity of up to 50% 1 .…”

“…Pleural effusions from pleuroperitoneal leaks are a rare but well‐recognized complication of peritoneal dialysis (PD). They normally arise early in the course of PD with 76% of reported cases occurring within 6 months and 89% within 12 months 1–3 . Risk factors include congenital diaphragmatic defects, diaphragmatic muscular hypotonia, previous episodes of peritonitis, lymphatic drainage disorders, and polycystic kidney disease 1,2,4 .…”

Non-infectious complications of peritoneal dialysis and peritoneal scintigraphy

“…Les patients suspectés d'une fuite pleuro péritonéale présentent généralement une dyspnée et ont tendance à avoir des épanchements pleuraux avec un transsudat et un taux élevé de glucose. (18), sur les 27 scintigraphies réalisées, 70% retrouvaient une fuite pleuropéritonéale. La majorité de ces fuites ont été détectées dans les 12 minutes suivant l'administration du traceur avec une forte prépondérance de survenue dans l'hémithorax droit.…”

Imaging and leaks in peritoneal dialysis

“…Les acquisitions sont réalisées toutes les 5 minutes durant 1 heure [12]. Outre les brèches pariétales, elle permet principalement de diagnostiquer l'hydrothorax qui est autrement identifiable par radiographie du thorax et ponction pleurale avec analyse du liquide qui est transsudatif [13].…”