Hydrothorax in continuous ambulatory peritoneal dialysis: peritoneoscintigraphy in a case of spontaneous closure of pleuroperitoneal communication

Pleuroperitoneal communication after bacterial peritonitis and total gastrectomy for gastric neuroendocrine tumors: a case report and brief literature review

Background

Peritoneal dialysis (PD) is associated with various complications, some of which may result in its discontinuation. Pleuroperitoneal communication (PPC) is commonly recognized by the presence of a diaphragmatic defect and pressure elevation in the abdominal cavity due to the dialysate. PPC is unpredictable and its presence prevents the continuation of PD. We present the clinical course and pathological findings of PPC in a PD patient after bacterial peritonitis and total gastrectomy for gastric neuroendocrine tumors. We provide a brief review of PD-related complications that develop due to a non-infectious pathology, including those related to catheter use and an elevated intra-abdominal pressure.

Case presentation

A 65-year-old Japanese man, who had been receiving PD treatment for 1 year, visited our hospital owing to a cloudy dialysate. Bacteria were detected in the dialysate. He had been previously diagnosed with gastric neuroendocrine tumors and gastrectomy had been planned. On admission, we started a 14-day antibiotic treatment for PD-related peritonitis. The patient showed a good clinical course. Gastrectomy was performed as planned, and the postoperative course was uneventful. During the perioperative period, PD was temporally changed to hemodialysis. Five weeks after the gastrectomy, PD treatment was resumed with gradual increase in the exchange volume. After returning to PD overnight, using an automated peritoneal dialysis machine, the patient complained of breathing difficulty and he gained weight. Right-sided pleural effusion was observed on a chest radiograph, and PPC was confirmed by scintigraphy when a mixture of technetium-99m and dialysate was seen entering the right hemithorax within 120 min. The patient did not consent to surgery for the PPC and he hoped to continue to receive PD treatment conservatively. We advised the patient to undergo dialysate exchange in a semi-seated position, and he was prohibited from lying down during the daytime. He continued PD treatment without signs of pleural effusion and over-volume.

Conclusions

This case of PPC occurring after bacterial peritonitis and total gastrectomy for gastric neuroendocrine tumors in a PD patient demonstrates the necessity of recognizing the PPC pathology in PD management and establishing methods for preventing PPC development after bacterial peritonitis or surgical procedures.

Unexplained Exudative Pleural Effusion in Chronic Peritoneal Dialysis Patients

Background

Although the clinico-pathological entity of uremic pleuritis has long been recognized, its clinical significance remains poorly defined.

Methods

We retrospectively studied 82 chronic peritoneal dialysis (PD) patients that had pleural effusion. The pattern of diagnosis and clinical outcome were reviewed.

Results

10 patients had overt fluid overload and thoracocentesis was not performed, 23 had other specific diagnoses, 15 had transudative effusion due to fluid overload, 12 had unexplained transudative effusion, and 22 patients had unexplained exudative effusion. The 3-year actuarial survival was 40.9% and 83.3% for patients with unexplained exudative and transudative effusion respectively ( p = 0.012); technique survival was 74.2% and 90.9% respectively ( p = 0.006). For patients with unexplained exudative effusion, 11 patients had their PD regimen intensified: they had a higher 3-year actuarial survival than those with their dialysis regimen unchanged (100.0% vs 52.6%, p = 0.04).

Conclusion

Unexplained exudative pleural effusion is not uncommon in chronic PD patients. These patients have a high mortality; an intensive dialysis regimen may be considered.

Pleuroperitoneal communication of peritoneal dialysis demonstrated by multidetector-row CT peritoneography

Hydrothorax as a result of pleuroperitoneal communication is an uncommon complication in continuous ambulatory peritoneal dialysis (CAPD) patients. CT peritoneography is a useful method for evaluating a wide variety of complications due to CAPD. We report a case of pleuroperitoneal communication with specific imaging features on multidetector-row CT peritoneography (MDCT).

Peritoneal-mediastinal leakage complication of peritoneal dialysis

The authors report a case of mediastinal fluid collection resulting from peritoneal-mediastinal communication after continuous ambulatory peritoneal dialysis (CAPD). To the best of the authors' knowledge, this is the first reported case in the medical literature. A dry cough developed in the patient who had been receiving CAPD for 4 years. A mediastinal mass owing to peritoneal leakage of dialysate to the mediastinum was confirmed by a computed tomography scan taken 4 hours after the intraperitoneal infusion of contrast-mixed dialysate. The leakage persisted for 12 weeks after the discontinuation of CAPD fluid instillation.