Home About us Current issue Back issues Submission Instructions Advertise Contact Login   

Search Article 
  
Advanced search 
 
Saudi Journal of Kidney Diseases and Transplantation
Users online: 34 Home Bookmark this page Print this page Email this page Small font sizeDefault font size Increase font size 
 


 
Table of Contents   
CASE REPORT  
Year : 2012  |  Volume : 23  |  Issue : 1  |  Page : 106-109
Unilateral recurrent pleural effusion in a renal transplant patient


Department of Nephrology, Jaslok Hospital and Research Centre, Mumbai, India

Click here for correspondence address and email

Date of Web Publication3-Jan-2012
 

   Abstract 

Pleural effusion is a frequent complication in patients undergoing hemodialysis (HD). We report a patient on HD with a novel cause of recurrent unilateral pleural effusion. A 45-year-old female patient on long-term maintenance HD presented to us with recurrent unilateral pleural effusion. She had a history of poor quality dialysis, severe anemia and severe hypertension. Despite correcting these factors and even after undergoing successful renal transplantation, she continued to have recurrent effusion. Left upper extremity venography demonstrated severe stenosis of the subclavian vein and an increased venous flow in the ipsilateral arteriovenous (AV) fistula. Ligation of the AV fistula led to dramatic resolution of the pleural effusion. Hemodialysis patients who develop unexplained pleural effusions ipsilateral to a functioning AV fistula should be investigated for stenosis in the brachiocephalic vein, particularly those patients who have had previous catheterizations of the jugular or subclavian veins on the same side as the effusion. Correcting the stenosis by venous angioplasty and/or ligation of the ipsilateral fistula can dramatically resolve the pleural effusion. A high index of suspicion is required to diagnose this complication for meaningful intervention.

How to cite this article:
Binnani P, Gupta R, Kedia N, Bahadur M M. Unilateral recurrent pleural effusion in a renal transplant patient. Saudi J Kidney Dis Transpl 2012;23:106-9

How to cite this URL:
Binnani P, Gupta R, Kedia N, Bahadur M M. Unilateral recurrent pleural effusion in a renal transplant patient. Saudi J Kidney Dis Transpl [serial online] 2012 [cited 2014 Jul 25];23:106-9. Available from: http://www.sjkdt.org/text.asp?2012/23/1/106/91312

   Introduction Top


Pleural effusion is a frequent complication in patients undergoing hemodialysis (HD). The incidence of pleural effusion in patients receiving long-term HD is reported to be between 16 and 20.2% by different authors. [1],[2] Common causes of pleural effusion are congestive heart failure, infection, neoplasm and so-called uremic pleuritis. [2] Uremic pleuritis is a diagnosis of exclusion, estimated to develop in 3-10% of patients with advanced renal failure. [3] Pleural effusion generally resolves with continued dialysis over several weeks, although some may recur later. [4] Rarely, urinothorax can occur as a complication of obstructive, inflammatory or malignant renal disease. [5]

We report a patient on HD with a novel cause of pleural effusion. Severe stenosis in the left subclavian vein with increased venous flow in the ipsilateral arteriovenous (AV) fistula was seen in association with the appearance of recurrent left sided pleural effusion. Percutaneous venous angioplasty failed to correct the stenosis and ligation of the AV fistula led to dramatic resolution of the pleural effusion. The etiology, diagnosis and management of this uncommon complication of central venous cannulation are briefly reviewed.


   Case Report Top


A 45-year-old female patient was diagnosed to have chronic kidney disease with small contracted kidneys in 2001. In 2004, she was started on dialysis using a left internal jugular vein catheter as vascular access. A left brachial AV fistula was constructed at a later date.

She was referred to us in May 2006 for renal transplantation, her husband being a willing donor. Her main problems at admission included: severe muscle wasting, uremic peripheral neuropathy, poor dialysis, severe hypertension (BP-200/100 mmHg), orthopnea and severe anemia. The important sign on physical examination at admission was decreased breath sounds and dullness in the left hemithorax. Signs of congestive heart failure were absent. The blood count and routine serum biochemistry were unremarkable. The chest X-ray showed a massive left-sided pleural effusion [Figure 1]. The ultrasound and magnetic resonance imaging (MRI) of the abdomen showed necrotic generalized abdominal lymphadenopathy. A 2D echocardiogram was normal.
Figure 1: X-ray of the chest showing a massive left sided pleural effusion.

Click here to view


She was put on intensified dialysis regimen, five drugs anti-tuberculous treatment (ATT) in view of necrotic lymphadenopathy and intravenous iron and erythropoietin for severe anemia. Therapeutic pleural aspiration was done and two liters of straw-colored fluid was removed. Fluid analysis showed a cell count of 55 (neutrophils, 55%; lymhocytes, 45%), protein of 1.8 gm/dL, albumin of 0.7 gm/dL, and ADA of 18. The fluid lactate dehydrogenase (LDH) was 222 IU/L and serum albumin was 2.7 mg/dL. Cytological studies of the fluid, antinuclear antibody, smear for acid-fast bacilli and routine cultures were negative. Pleural fluid amylase was normal. Given the negative results of cytological and microbiological studies, uremic pleurisy or fluid overload, complicated by severe anemia was considered the most likely diagnosis.

The patient continued to have recurrent symptomatic left pleural effusion requiring multiple pleural fluid aspirations; each time around 1000 mL fluid was removed.

With intensified dialysis, the patient's general condition gradually improved. The frequency of pleural aspirations decreased but she still required it. A decision was taken to proceed with renal transplantation after completing five months of ATT. In the post-operative period, she achieved normal renal function, but on day three of transplantation, she again developed orthopnea and chest X-ray revealed a massive left pleural effusion. She developed a pneumothorax post-pleurocentesis, requiring intercostal drainage. The diagnosis of the recurrent pleural effusion remained a dilemma. The possible differential diagnoses of fluid overload, cardiac failure, drug-resistant tuberculosis, lymphoma and hypothyroidism had been ruled out.

The puzzle was finally solved when the patient was re-examined. She had dilated veins on the left side of the chest and left upper limb secondary to high flow in the left brachial AV fistula [Figure 2]. She underwent left upper extremity venography which revealed blocked left subclavian vein. Coil embolization of the fistula and percutaneous angioplasty of the stenotic vein were unsuccessful. Later, she underwent surgical closure of the AV fistula. In the following days, the patient's dyspnea progressively improved together with complete disappearance of the pleural effusion. No recurrence of the pleural effusion has been observed after more than two years of follow-up [Figure 3].
Figure 2: Clinical photograph showing dilated veins on the left side of the chest and left upper limb due to high-flow left brachial arterio-venous fistula.

Click here to view
Figure 3: X-ray of the chest showing resolution of the left-sided pleural effusion.

Click here to view



   Discussion Top


In patients who are on maintenance HD, only a few conditions commonly cause transudative pleural effusions: heart failure, fluid overload, the nephrotic syndrome, and peritoneal dialysis. The presence of a large effusion confined to the left side makes heart failure, fluid overload, and hypoalbuminemic disorders less likely as causes. [6]

Our patient had no history of previous peritoneal dialysis. Heart failure may be associated with unilateral left-sided pleural effusion (in less than 10% cases), but a massive unilateral effusion would be very unusual. Furthermore, there was no other clinical evidence of heart failure in this patient. Uncommon causes of transudative effusions include constrictive pericarditis, myxedema, atelectasis of the lungs, obstruction of the superior vena cava, pulmonary embolism and urinary leakage into the thorax. But they are rarely massive. Among these possibilities, inadequate dialysis with fluid overload was considered initially as the most likely cause of recurrent pleural effusion. Her HD regimen was intensified; however, the pleural effusion did not decrease. Other investigations such as MRI and echocardiography did not contribute significant data. Antitubercular treatment was given empirically in this patient. The patient continued to have recurrent unilateral pleural effusion despite correcting inadequate HD and fluid overload and even after undergoing successful renal transplantation.

The combination of brachiocephalic stenosis and the high venous flow rates provided by an ipsilaterally situated AV fistula would elevate the venous pressure, which would impede the drainage of the left superior intercostal vein into the left subclavian and brachiocephalic veins. This resulted in unilateral massive pleural effusion . [7]

In recent years, catheterization for temporary or permanent access for HD has increased dramatically. A well-known complication of such catheterizations is subclavian vein stenosis. For these reasons, an increase in the incidence of pleural effusions associated with high brachiocephalic venous pressure should be anticipated in HD patients. [8] The association of stenosis of the left brachiocephalic vein with ipsilateral pleural effusion is rare. A high index of suspicion is required to diagnose and treat this complication for meaningful intervention to avoid associated morbidity and mortality. Correcting the stenosis by venous angioplasty and/or ligation of the ipsilateral fistula can dramatically resolve the pleural effusion.

 
   References Top

1.Bakirci T, Sasak G, Ozturk S, Akcay S, Sezer S, Haberal M. Pleural effusion in long-term hemodialysis patients. Transplant Proc 2007; 39(4):889-91.  Back to cited text no. 1
    
2.Jarrat MJ, Sahn SA. Pleural effusion in Hospitalized patients receiving long-term hemodialysis. Chest 1995;108(2):470-4.  Back to cited text no. 2
    
3.Maher JF. Uremic pleuritis. Am J Kidney Dis 1987;10(1):19-22.  Back to cited text no. 3
    
4.Al-Harby A, Al-Furayh O, Al-Dayel F, Al-Mobeireek A. Pleural effusion in a patient with end-stage renal disease. Ann Saudi Med 2006;26(2):145-6.  Back to cited text no. 4
    
5.Hendricks J, Michielson D, Van Schil P, Wyndaele JJ. Urinothorax: A rare pleural effusion. Acta Chir Belg 2002;102(4):274-5.  Back to cited text no. 5
    
6.Muthuswamy P, Alausa M, Reilly B. The effusion that would not go away. N Engl J Med 2001;345(10):756-9.  Back to cited text no. 6
    
7.Wright RS, Quinones-Baldrich WJ, Anders AJ, et al. Pleural effusion associated with ipsilateral breast and arm edema as a complication of subclavian vein catheterization arterio-venous fistula formation for hemodialysis. Chest 1994;106:950-2.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Ruiz EM, Gutierrez E, Martínez A, et al. Unilateral pleural effusions associated with stenoses of left brachiocephalic veins in haemodialysis patients. Nephrol Dial Transplant 2005;20(6):1257-9.  Back to cited text no. 8
    

Top
Correspondence Address:
Pooja Binnani
Department of Nephrology, Jaslok Hospital and Research Centre, Mumbai-400026
India
Login to access the Email id


PMID: 22237229

Get Permissions



    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

Top
   
 
 
    Similar in PUBMED
    Search Pubmed for
    Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  
 


 
    Abstract
   Introduction
   Case Report
   Discussion
    References
    Article Figures
 

 Article Access Statistics
    Viewed2950    
    Printed59    
    Emailed0    
    PDF Downloaded208    
    Comments [Add]    

Recommend this journal