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| Year : 1999 | Volume
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| Issue : 2 | Page : 163-166 |
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| Acute Hydrothorax Complicating continuous Ambulatory Peritoneal Dialysis: A Case Report and Review of Literature |
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Mohammad Chibab Kechrid, Ghulam Hassan Malik, Jamil F Shaikh, Suleiman Al-Mohaya, Jamal S Al-Wakeel, Hazem El Gamal
Department of Internal Medicine, Security Forces Hospital, Riyadh, Saudi Arabia
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 Abstract | | |
We describe here hydrothorax that occurred in a patient on continuous ambulatory peritoneal dialysis (CAPD) and highlight the problems of diagnosis and management. A 48 years-old man with history of obstructive uropathy secondary to urolithiasis was stared on CAPD when he reached end-stage renal failure. Two months later, he was admitted with two days history of shortness of breath on exertion and dry cough increasing in supine position. Chest examination was suggestive of right sided pleural effusion confusion confirmed by chest X-ray. Radioisotope Technetium 99m labeled albumin instilled through the peritoneal catheter was detected in the right pleural fluid confirming the peritoneo-pleural leak. The peritoneal dialysis (PD) was discontinued and the patient was switched to hemodialysis. The pleural effusion subsided and has not recurred for the following three years.
How to cite this article:
Kechrid MC, Malik GH, Shaikh JF, Al-Mohaya S, Al-Wakeel JS, El Gamal H. Acute Hydrothorax Complicating continuous Ambulatory Peritoneal Dialysis: A Case Report and Review of Literature. Saudi J Kidney Dis Transpl 1999;10:163-6 |
How to cite this URL:
Kechrid MC, Malik GH, Shaikh JF, Al-Mohaya S, Al-Wakeel JS, El Gamal H. Acute Hydrothorax Complicating continuous Ambulatory Peritoneal Dialysis: A Case Report and Review of Literature. Saudi J Kidney Dis Transpl [serial online] 1999 [cited 2021 Apr 19];10:163-6. Available from: https://www.sjkdt.org/text.asp?1999/10/2/163/37224 |
| Introduction | |  |
Continuous ambulatory peritoneal dialysis (CAPD) is an established mode of replacement therapy in patients with end-stage renal disease (ESRD). A variety of complications have been reported in patients on CAPD. [1] Some of the complications of CAPD are related to increase intra-abdominal pressure that results in accumulation of dialysis fluid in the pleural cavity (hydrothorax). [2] This complication has also been reported in patients on acute or chronic intermittent peritoneal dialysis (IPD) in elderly patient from our center no such complication was reported. [5]
We describe here hydrothorax that occurred in a patient on CAPD and highlight the problems of diagnosis and management.
| Case Report | | |
A 48-years-old man with history of obstructive uropathy secondary to urolithiasis underwent left-side nephrectomy for nonfunctioning kidney in 1987. On follow up three years later, he developed nephritic range proteinuria. An open right kidney biopsy was performed in 1991, showing focal and segmental glomerulosclerosis. He did not respond to steroids and cyclophosphamide, and reached ESRD in 1994. A Tenckhoff catheter was surgically instead in November 1994 and he was started on IPD in the hospital with 20 hourly cycles twice an week. He was doing well and remained asymptomatic. However, because of patient preference, arterio-venous fistula was created for him and he was switched to maintenance hemodialysis in January 1995. After 10 months on hemodialysis, the arterio-venous fistula functioned poorly and forced us to return the patient to peritoneal dialysis. A new Tenckhoff catheter was inserted, and CAPD was initiated one week late. He performed CAPD by himself and was apparently doing well. However, two months later, he was admitted with two days history of shortness of breath on exertion and dry cough increasing in supine position. He had gained three kilograms of weight but was not edematous. He was afebrile and chest examination was suggestive of right sided pleural effusion confirmed by chest X-ray [Figure - 1].
The pleural fluid was clear with glucose level of 14.4 mmol/L (blood sugar was 6.1 mmol/L). Protein of 15g/L, and lactic dehydrogenase (LDH) level of 47 (normal = 50-195µ/L). Fluid white cell count was 2,500 cells/ml and culture of the fluid was sterile and no malignant cells were noticed. The high glucose content, low protein and low-LDH were suggestive of peritoneopleural leak. In view of the significant right pleural effusion a therapeutic thoracocentesis succeeded in draining 1,000 ml of fluid, followed by 20 cycles of hourly exchanges of IPD, keeping the patient in semi-sitting position. However, the pleural effusion recurred and had to be drained twice.
Five milliliters of sterile methylene blue were injected into 2,000 ml of 1.5% dextrose PD fluid, and the fluid was instilled through the Tenckhoff catheter into the peritoneal cavity. After 30 minutes of in dwelling, a 40 ml sample of pleural fluid was still colorless. The test was repeated, but remained non-conclusive. Radioisotope Technetium 99m labeled albumin instilled through the peritoneal catheter was detected in the right pleural fluid confirming the peritoneo-pleural leak [Figure - 2]. Computed tomography of the chest did not reveal any diaphragmatic lesion.
The PD was discontinued and the patient was switched back to hemodialysis. The pleural effusion subsided and did not recur over for the following three years.
| Discussion | | |
Edwards and Unger reported the first case of hydrothorax complicating acute peritoneal dialysis in 1967. [7] Ina collaborative studies from 161 centers in Japan, 50 cases (1.6%) with this complication were reported out of 3,135 patients on CAPD. [8]
There have been more than 70 single reported cases of hydrothorax complicating peritoneal dialysis descried in the literature up to 1993.[2] Contrary to the present case most cases were reported in females. [2],[8] Similar to our present case, hydrothorax has been reported to occur on the right side in 88% of the case. [8] It has been suggested that the heart and the pericardium on the left side may cover the left-sided hydrothorax. [2] More ever, the predominance of the rightsided occurrence of pleural effusion may be due to the presence of more numerous lymphatics on right side as well as more anatomical defects in the right hemi-diaphragm. [2],[8]
The pathogenesis of this complication in peritoneal dialysis is still debated. Various mechanisms were suggested including a diaphragmatic leak with an anatomical pleuroperitoneal communication, [9] a congenital weakness of the diaphragm or a bleb with an acquired rupture. [4] Increases abdominal pressure has been suggested to be the initiating event in children, [4] as well as in adults. [2] The negative intra-thoracic pressure results in a gradient that drives fluid from the high-pressure peritoneum to the lowpressure pleural space through potential diaphragmatic defects, such as those around the major vessels and esophagus or through the diaphragmatic formamian. [8] Anatomical defects in the diaphragm have not been demonstrated by injection of dyes. [3],[4],[7] However, successful repair of the anatomical defects of the diaphragm has been reported in some cases. [10],[11]
It has been suggested that there is a bidirectional flow of fluid, since interruption of peritoneal dialysis is associated with disappearance of fluid from the chest cavity. [12] Delayed onset large hydrothorax, although uncommon, is a serious complication reported in chronic PD. [4],[13]
Hydrothorax is a rate complication of CAPD. Diagnosis is not usually straight forward. Intra-peritoneal methylene blue followed by thoraco-centesis as mentioned by some authors, [14],[15] could not confirm the diagnosis in the present case, this method has been found to be unreliable by other authors as well. [13],[16] Technetium 99m labeled macro-aggregated albumin was confirmatory in the present case, and this test has been found useful in other studies and remains the best confirmatory test for diagnosis of hydrothorax complicating CAPD [13],[16],[17] Regular surveillance may be necessary to detect pleural effusion in patients on CAPD.
Although surgical repair remains an option, most of the reports from the literature favor the conservative management. Successful long-term resolution of hydrothorax following brief interruption of CAPD was reported in 27 (54%) out of 50 patients. [8] Furthermore, a brief interruption of PD with pleural instillation of tetracycline was found to be successful.[13] Some patients will do well on changing to OPD if continuation of peritoneal dialysis is deemed unavoidable. [9] An alternative approach included continuing CAPD with smaller volumes of dialysate in a semi-sitting position.[18] Our patient was switched back to hemodialysis because of recurrence of effusion.
In conclusion, hydrothorax is a serious complication of CAPD, which may compromise treatment of CAPD. Technetium 99m labeled macro-aggregated albumin is a reliable confirmatory test of pleuro-peritoneal communication. Affected patients may need to be switched temporarily or permanently to hemodialysis.
| Acknowledgment | | |
The authors express their gratitude to Ms. Sita J. Benedicto for her secretarial assistance in the preparation of this manuscript and to Ms. Alice Haddadin for help in the search of literature.[19]
| References | | |
| 1. | Gokal R, Drukker IN, Parsons and Maher. Replacement renal function by dialysis (peritoneal infections, hernias and related complications) Jacobs C, Kjellstrand CM, Koch KM, Winchester FK, (eds). Kluwer Academic Publishers 1996;657-87.  |
| 2. | Bargman JM. Complications of peritoneal dialysis related to increased intraabdominal pressure. Kidney Int suppl 1993;440:S75-80. |
| 3. | Rudnick MR, Coyle JF, Beck LH, Mc Curdy DK. Acute massive hydrothorax complication peritoneal dialysis: report of 2 cases and a review of the literature. Cli Nephrol 1979;12:28-44. |
| 4. | Lorentz WB Jr. Acute hydrothorax during peritoneal dialysis. J Pediatr 1979;94:417-9. [PUBMED] |
| 5. | Mitwalli A, Malik GH, Al-wakeel, et al. Intermittent peritoneal dialysis in the elderly, experience at Security Forces Hospital, Riyadh, Saudi Arabia. Geriatric Nephrology and Urology 1996;8:326. |
| 6. | SCOT data. Saudi J Kidney Dis Transplant 1997;8:326. |
| 7. | Edwards SR, Unger AM. Acute hydrothorax-a new complication of peritoneal dialysis. JAMA 1967;199:853-5. [PUBMED] |
| 8. | Nomoto Y, Suga T, Nakajima K, et al. Acute hydrothorax in continuous ambulatory peritoneal dialysis: a collaborative study of 161 centers. Am J Nephrol 1989;9:363-7. [PUBMED] |
| 9. | Mion C. Practical use of peritoneal dialysis: a replacement of renal function by dialysis: in replacement of renal function by dialysis. Maher JF (ed): Khuwer Academic Publisher s 1989;p560. |
| 10. | Pattison CW, Rodger RS, Adue D, Michael J, Mathews HR. Surgical treatment of hydro-thorax complicating continuous ambulatory peritoneal dialysis. Clin Nephrol 1984;21:191-3. |
| 11. | Mallonga ET, van Coevorden F, Boeschoten EW, Southwood J, Krediet RT. Surgical problems in continuous ambulatory peritoneal dialysis (CAPD) Neth J Surg 1982;34:117-22. |
| 12. | Winchester JF, Kriger FL. Fluid leaks prevention and treatment. Perit Dial Int 1994;14-Suppl 3:S43-8. [PUBMED] [FULLTEXT] |
| 13. | Benz RL, Scleifer CR. Hydrothorax in continuous ambulatory peritoneal dialysis successful treatment with intrapleural tetracycline and a revieew of the literature. Am J Kidney Dis 1985;5:136-40. |
| 14. | O'Connor J, Rutland M. Demonstration of pleuro-peritoneal communication with radio-nuclide imaging in a CAPD patient (letter) Perit Dial Bull 1981;1:153. |
| 15. | Sceldewaert R, Bogaerts Y, pauwels R, Van Der Straeten M, Ringoir S, Lameire N. Management of a massive hydrothorax in a CAPD patient: a case report and a review of the literature. Am J Kidney Ds 1985;5:1136. |
| 16. | Adam WR, Arkles LB, Gill G, Meagher EJ, Thomas GW. Hydrothorax with peritoneal dialysis: rdionuclide detection of a pleuroperitoneal connection. Aust N Z J Med 1980;10:330-2. [PUBMED] |
| 17. | Lepage S, Bisson G, Verreault J, Plante GE. Massive hydrothorax complicating |
| 18. | peritoneal dialysis. Isotopic investigation (peritoneopleural scintigraphy) Clin Nucl Med 1993;18(6):498-501. |
| 19. | Townsend R, Fragola JA, Hydrothorax in a patient receiving continuous ambularoty peritoneal dialysis: successful treatment with intermittent peritoneal dialysis. Arch Intern Med 1982;142:1571-2. |
Correspondence Address:
Mohammad Chibab Kechrid
Department of Internal Medicine, Security Forces Hospital, P.O. Box 3643, Riyadh 11481
Saudi Arabia
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PMID: 18212427 
[Figure - 1], [Figure - 2] |
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