AP Yim

CC Szeto

CM Van Dijk

D Shemin

Dwarkanathan Ranganathan

KM Chow

L Ortiz

M Le Blanc

P Pankaj

P Saillen

RG Ramon

S Tang

SR Edward

Vincent D'Intini

Y Nomoto

Yeoungjee Cho

Journal of Medical Case Reports

English

PubMed

Springer - Publisher Connector

CASE REPORT Open Access
Acute hydrothorax complicating peritoneal
dialysis: a case report
Yeoungjee Cho1, Vincent D’Intini1, Dwarkanathan Ranganathan1,2*
Abstract
Introduction: Acute hydrothorax is an uncommon but a well-recognized complication of peritoneal dialysis. No
single test is definitive for diagnosis. Although it is not a life-threatening condition, hydrothorax often requires
abandonment of peritoneal dialysis. Delay in diagnosis can lead to worsening of the clinical status.
Case Presentation: A 33-year-old Caucasian woman with lupus, who was successfully treated with temporary
peritoneal dialysis 17 years previously, presented with acute dyspnea and a right pleural effusion after
recommencing peritoneal dialysis. Investigations eliminated infective, cardiac, and primary respiratory causes.
Peritoneal dialysis-related hydrothorax was suggested by biochemistry, and a pleuroperitoneal leak was definitively
confirmed by using a Tc-99 m DTPA (diethylene triamine penta-acetic acid) scintigraphy scan. Subsequently, she
underwent video-assisted thoracoscopy-guided talc pleurodesis and was able to return successfully to peritoneal
dialysis.
Conclusion: Although our case is not the first report that describes the occurrence of acute hydrothorax in
peritoneal dialysis, it is an important condition to recognize for the wider general medical community.
Furthermore, this case demonstrates that peritoneal dialysis can be continued with a hydrothorax, provided the
underlying cause can be corrected. We review the literature pertaining to the utility and reliability of different
diagnostic approaches to hydrothorax.
Introduction
Peritoneal dialysis-(PD) related hydrothorax was first
reported in 1967 by Edward and Unger [1]. The preva-
lence of hydrothorax varies, ranging from 1.6% [2] to 6%
of adult PD patients [3]. Transudative pleural effusion
develops, more commonly involving the right side, and
usually occurs immediately after starting PD or a few
days later [4]. The patients may remain asymptomatic
or have sudden dyspnea, decrease in ultrafiltration, or
pleuritic chest pain.
Possible pathogenetic mechanisms include congenital
diaphragmatic defects, a disorder of lymphatic drainage,
and pleuroperitoneal pressure gradient [4-6]. The theory
of congenital diaphragmatic defects explains the prepon-
derance of right-sided hydrothorax because left-sided
defects, as such, are covered by the heart and pericar-
dium, thereby protecting against the leak. Reported risk
factors for developing hydrothorax include PD peritoni-
tis; it may exacerbate the continuity defects in the pleur-
operitoneal structure [7]. However, transudative pleural
effusion can be due to multiple causes other than PD,
such as congestive heart failure, hypoalbuminemia, or
fluid overload for any reason.
An accurate method of diagnosing pleuroperitoneal
communication is important, as treatment efforts using
hypertonic peritoneal exchanges to improve fluid status
may worsen the hydrothorax [8]. Unfortunately, no sin-
gle definitive test exists for the diagnosis and localiza-
tion of the defect for potential intervention.
Case presentation
A 33-year-old Caucasian woman with end-stage renal
failure secondary to systemic lupus erythematosus
started PD in December 2008. She had previously been
treated with PD without complication 17 years before,
in the context of acute kidney injury, from which she
recovered. Exact details of PD were unavailable, but it
was recalled to be of short duration and probably of
* Correspondence: dwarakanathan_ranganathan@health.qld.gov.au
1Renal Unit, Royal Brisbane & Women’s Hospital, Level 9 Ned Hanlon
Building, Bowen Bridge Road, Herston, Brisbane, Queensland, 4029, Australia
Full list of author information is available at the end of the article
Cho et al. Journal of Medical Case Reports 2010, 4:355
http://www.jmedicalcasereports.com/content/4/1/355 JOURNAL OF MEDICAL
CASE REPORTS
© 2010 Cho et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
small fill volume. The patient denied any history of trau-
matic injury to the chest or diaphragmatic surgery.
A Tenckhoff catheter was inserted 28 days before
commencement of PD without complication. Her first
exchange revealed asymptomatic slightly cloudy dialysate
with 210 white cells [82% polymorphonuclear cells] and
negative growth and was treated as culture-negative PD
peritonitis.
One week later, she presented with sudden onset of
dyspnea associated with right pleuritic chest pain. Chest
X-ray (Figure 1) showed right pleural effusion.
Thoracentesis was performed for symptomatic relief.
Pleural fluid biochemistry results were consistent with
transudate, according to Light’s criteria (Table 1). Cul-
ture of pleural aspirate showed no evidence of infection.
Clinically, no evidence of lupus flare or nephrotic syn-
drome was noted.
Pleural fluid biochemistry results were consistent with
PD-related hydrothorax. An effusion reaccumulated
with further PD treatment. It was unclear whether poor
dialysis (uremia) or ultrafiltration was contributing to
the effusion. Tc-99 m DTPA scintigraphy was per-
formed to confirm pleuroperitoneal leakage, showing
prompt (within 15 minutes) appearance of tracer in the
pleural space on the right side with no evidence of tra-
cer entering the left hemithorax (Figure 2). Thus, the
etiology of hydrothorax likely was due to congenital dia-
phragmatic defects, exacerbated by persistently elevated
intraabdominal pressure from PD.
The patient was temporarily transferred to hemodialy-
sis via a tunneled line and underwent right video-
assisted thoracoscopic surgery and talc pleurodesis. An
intraoperative methylene blue test failed to identify the
pleuroperitoneal defect. Two months after the proce-
dure, she successfully recommenced PD without reoc-
currence of hydrothorax.
Discussion
Diagnostic approaches to PD-related hydrothorax can be
broadly divided into biochemical and imaging approaches.
The basis of the biochemical approach is that PD-
related hydrothorax is believed to have a high pleural-
fluid glucose concentration. However no validated
reference range exists to aid diagnosis. Some investiga-
tors believe that only a pleural fluid glucose concentra-
tion greater than 16.5 mmol/L (300 mg/dl) would be
diagnostic [9].
Chow and others [10] have hypothesized that, given
dynamic movement of dialysate, an absolute glucose-
concentration level cannot be used to diagnose PD-
related hydrothorax. The pleural fluid-to-serum glucose
concentration gradient of greater than 2.77 mmol/L
(50 mg/dl) was proposed as the cut-off to diagnose the
condition [10]. Subsequent studies, however, found this
to be unreliable [11], and generally any pleural-fluid
glucose concentration greater than serum is considered
to be highly supportive of PD-related hydrothorax.
All studies assessing imaging techniques have very
small subject numbers, and none of the test methods is
very sensitive. Radionuclide scan (for example, Tc-99 m
DTPA) is associated with sensitivity of 40% to 50%
[11,12]. A case report by Ortiz and others [13] showed
that the yield of scintigraphy in a child with hydrothorax
could be improved if the scanning were performed
immediately after complete drainage of the hydrothorax,
possibly because of relief of this pressure.
The methylene blue test in one study showed no sensi-
tivity and is associated with a risk of chemical peritonitis
[11]. Contrast computed tomography peritoneography
was associated with 33% sensitivity in one study, with
added risk of nephrotoxicity in those with residual renal
function [11,12].
Conclusion
PD-related hydrothorax is an important complication of
PD to be recognized and treated in a timely fashion.
Current diagnostic strategies to confirm PD-related
hydrothorax are unsatisfactory. Pleural-fluid glucose
concentration that is greater than that of serum is most
Figure 1 Chest X-ray showing right pleural effusion.
Table 1 Serum, peritoneal, and pleural fluid biochemistry
Fluid type Glucose
[mmol/L]
Protein
[g/L]
Lactate dehydrogenase
Serum 5.1 71 282
Peritoneal 31.1 < 5 8
Pleural 12.5 < 5 28
Cho et al. Journal of Medical Case Reports 2010, 4:355
http://www.jmedicalcasereports.com/content/4/1/355
Page 2 of 3
probably due to pleuroperitoneal leak. Methods to
improve the sensitivity of a radionuclide scan should be
studied, such as thoracentesis to decrease intrathoracic
pressure. More important, it is imperative to recognize
that PD hydrothorax does not have to lead to abandon-
ment of PD as long as the etiology can be corrected.
Consent
Written informed consent was obtained from the patient
for publication of the case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
Acknowledgements
We thank Professor Robert Fassett for his comments.
Author details
1Renal Unit, Royal Brisbane & Women’s Hospital, Level 9 Ned Hanlon
Building, Bowen Bridge Road, Herston, Brisbane, Queensland, 4029, Australia.
2School of Medicine, The University of Queensland, Queensland, 4072,
Australia.
Authors’ contributions
All authors contributed to writing and reviewing of the manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 12 January 2010 Accepted: 8 November 2010
Published: 8 November 2010
References
1. Edward SR, Unger AM: Acute hydrothorax: a new complication of
peritoneal dialysis. JAMA 1967, 199:853-855.
2. Nomoto Y, Suga T, Nakajima K, Sakai H, Osawa G, Ota K, Kawaguchi Y,
Sakai T, Sakai S, Shibat M, Takahashi S: Acute hydrothorax in continuous
ambulatory peritoneal dialysis: a collaborative study of 161 centres. Am J
Nephrol 1989, 9:363-367.
3. Van Dijk CM, Ledesma SG, Teitelbaum I: Patient characteristics associated
with defects of the peritoneal cavity boundary. Perit Dial Int 2005,
25:367-373.
4. Ramon RG, Carrasco AM: Hydrothorax in peritoneal dialysis. Perit Dial Int
1998, 18:540-546.
5. Yim AP, Lee TW, Wan IY, Ng C: Pleuroperitoneal fistula. Ann Thorac Surg
2002, 73:1327.
6. Saillen P, Mossiman F, Wauters JP: Hydrothorax and end-stage chronic
renal failure. Chest 1991, 99:1010-1011.
7. Shemin D, Clark DD, Chazan JA: Unexplained pleural effusions in the
peritoneal population. Perit Dial Int 1989, 9:143-144.
8. Szeto CC, Chow KM: Pathogenesis and management of hydrothorax
complicating peritoneal dialysis. Curr Opin Pulmon Med 2004, 10:315-319.
9. Le Blanc M, Ouimet D, Pichette V: Dialysate leaks in peritoneal dialysis.
Semin Dial 2001, 14:50-54.
10. Chow KM, Szeto CC, Wong TYH, Li P: Hydrothorax complicating peritoneal
dialysis: diagnostic value of glucose concentration in pleural fluid
aspirate. Perit Dial Int 2002, 22:525-528.
11. Tang S, Chui WH, Tang AW, Li FK, Chau WS, Ho YW, Chan TM, Lai KN:
Video-assisted thoracoscopic talc pleurodesis in effective for
maintenance of peritoneal dialysis in acute hydrothorax complicating
peritoneal dialysis. Nephrol Dial Transplant 2003, 18:804-808.
12. Pankaj P, Pathak V, Sen IB, Verma R, Bhalla AK, Marwaha A, Pandey S: Use of
radionuclide peritoneography in the diagnosis of pleuroperitoneal
communication as a complication of continuous ambulatory peritoneal
dialysis. Ind J Nucl Med 2005, 20:4-8.
13. Ortiz L, Hazley D, Seikaly MG: Thoracocentesis helps diagnose
diaphragmatic defects in peritoneal dialysis patients. Pediatr Nephrol
2001, 16:105-106.
doi:10.1186/1752-1947-4-355
Cite this article as: Cho et al.: Acute hydrothorax complicating
peritoneal dialysis: a case report. Journal of Medical Case Reports 2010
4:355.
Figure 2 Tc-99 m DTPA scintigraphy showing pleuroperitoneal leakage.
Cho et al. Journal of Medical Case Reports 2010, 4:355
http://www.jmedicalcasereports.com/content/4/1/355
Page 3 of 3


Acute hydrothorax complicating peritoneal dialysis: a case report

Crossref

Acute hydrothorax in continuous ambulatory peritoneal dialysis: a collaborative study of 161 centres.

AM: Acute hydrothorax: a new complication of peritoneal dialysis.

Carrasco AM: Hydrothorax in peritoneal dialysis. Perit Dial Int

Chazan JA: Unexplained pleural effusions in the peritoneal population. Perit Dial Int

Chow KM: Pathogenesis and management of hydrothorax complicating peritoneal dialysis. Curr Opin Pulmon Med

Hydrothorax and end-stage chronic renal failure. Chest

Hydrothorax complicating peritoneal dialysis: diagnostic value of glucose concentration in pleural fluid aspirate. Perit Dial Int

KN: Video-assisted thoracoscopic talc pleurodesis in effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis. Nephrol Dial Transplant

MG: Thoracocentesis helps diagnose diaphragmatic defects in peritoneal dialysis patients. Pediatr Nephrol

Ng C: Pleuroperitoneal fistula. Ann Thorac Surg

Patient characteristics associated with defects of the peritoneal cavity boundary. Perit Dial Int

S: Use of radionuclide peritoneography in the diagnosis of pleuroperitoneal communication as a complication of continuous ambulatory peritoneal dialysis.

V: Dialysate leaks in peritoneal dialysis. Semin Dial

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2987964

Acute hydrothorax complicating peritoneal dialysis: a case report

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector

Crossref

Springer - Publisher Connector