Acute Hydrothorax Complicating Peritoneal Dialysis
Acute Hydrothorax Complicating Peritoneal Dialysis
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.
Peritoneal dialysis-(PD) related hydrothorax was first reported in 1967 by Edward and Unger. The prevalence of hydrothorax varies, ranging from 1.6% to 6% of adult PD patients. Transudative pleural effusion develops, more commonly involving the right side, and usually occurs immediately after starting PD or a few days later. 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. The theory of congenital diaphragmatic defects explains the preponderance of right-sided hydrothorax because left-sided defects, as such, are covered by the heart and pericardium, thereby protecting against the leak. Reported risk factors for developing hydrothorax include PD peritonitis; it may exacerbate the continuity defects in the pleuroperitoneal structure. 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. Unfortunately, no single definitive test exists for the diagnosis and localization of the defect for potential intervention.
Abstract and Introduction
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. The prevalence of hydrothorax varies, ranging from 1.6% to 6% of adult PD patients. Transudative pleural effusion develops, more commonly involving the right side, and usually occurs immediately after starting PD or a few days later. 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. The theory of congenital diaphragmatic defects explains the preponderance of right-sided hydrothorax because left-sided defects, as such, are covered by the heart and pericardium, thereby protecting against the leak. Reported risk factors for developing hydrothorax include PD peritonitis; it may exacerbate the continuity defects in the pleuroperitoneal structure. 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. Unfortunately, no single definitive test exists for the diagnosis and localization of the defect for potential intervention.
