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Liao HC, Chuang JH, Hsu HH, Chen KC, Chen JS. Video-assisted thoracoscopic surgery for thoracic empyema in patients on maintenance hemodialysis. Surg Endosc 2019; 34:1641-1647. [PMID: 31286249 DOI: 10.1007/s00464-019-06935-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Accepted: 06/12/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Thoracic empyema in uremic patients on maintenance hemodialysis is a challenging situation. The clinical characteristics are rarely reported, and the surgical outcomes remain unclear. We report our experience with video-assisted thoracoscopic surgery in these patients during 10-year period of time. METHODS Between 2005 and 2015, we retrospectively reviewed the clinical characteristics, bacteriological studies, and thoracoscopic surgical results of 23 empyema patients undergoing maintenance hemodialysis. RESULTS The mean patient age was 67.1 ± 12.9 years. All patients had additional preexisting systemic diseases. The mean duration of hemodialysis was 34.7 ± 25.8 months. The infections causing empyema were pneumonia in 11 (47.8%), blood stream infection in 8 (34.8%), and uremic pleuritis in 4 (17.4%). Among the 22 identified microorganisms, the most common pathogen was methicillin-resistant Staphylococcus aureus (31.8%). After thoracoscopic surgery, 8 patients (34.8%) required additional procedures for complications, including 2 patients who required repeated thoracoscopy for hemothorax and 6 (26.1%) patients who required open drainage for residual empyema. The mean hospital stay was 62.4 days, and 6 patients (26.1%) died in the hospital. Univariate and multivariate analyses revealed that maintenance hemodialysis longer than 5 years was a significant factor associated with in-hospital mortality (odds ratio: 14.8, 95% confidence interval 1.5-151.6; p < 0.0001). CONCLUSION While surgical management of thoracic empyema in uremic patients undergoing maintenance hemodialysis is associated with high rates of complication and mortality, thoracoscopic surgery is feasible, especially for patients undergoing hemodialysis for less than 5 years.
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Affiliation(s)
- Hsien-Chi Liao
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan South Road, Taipei, 100, Taiwan
| | - Jen-Hao Chuang
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan South Road, Taipei, 100, Taiwan
| | - Hsao-Hsun Hsu
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan South Road, Taipei, 100, Taiwan
| | - Ke-Cheng Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan South Road, Taipei, 100, Taiwan. .,Institute of Biomedical Engineering, College of Medicine and College of Engineering, National Taiwan University, Taipei, Taiwan.
| | - Jin-Shing Chen
- Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung Shan South Road, Taipei, 100, Taiwan
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Seo HM, Kim M, Kim H. Refractory exudative pleural effusion in patients with chronic kidney disease not receiving dialysis: A case report. Clin Case Rep 2019; 7:675-679. [PMID: 30997062 PMCID: PMC6452446 DOI: 10.1002/ccr3.2069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 01/26/2019] [Accepted: 02/03/2019] [Indexed: 11/27/2022] Open
Abstract
Although exudative pleural effusion can be caused by infections, malignancies, and connective tissue diseases, we need to consider uremic pleural effusion and pleuritis in differential diagnosis of exudative lymphocyte predominant pleural effusion in patients with chronic kidney disease not receiving dialysis.
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Affiliation(s)
- Hye Mi Seo
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Jeju National University HospitalJeju National UniversityJeju CityKorea
| | - Miyeon Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Jeju National University HospitalJeju National UniversityJeju CityKorea
| | - Hyunwoo Kim
- Division of Nephrology, Department of Internal Medicine, School of Medicine, Jeju National University HospitalJeju National UniversityJeju CityKorea
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Affiliation(s)
- Apurwa Karki
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 21610, United States
| | - Leonard Riley
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 21610, United States
| | - Hiren J Mehta
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 21610, United States
| | - Ali Ataya
- Division of Pulmonary, Critical Care and Sleep Medicine, University of Florida, 1600 SW Archer Rd, M452, PO Box 100225, Gainesville, FL 21610, United States.
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Habuka M, Ito T, Yoshizawa Y, Matsuo K, Murakami S, Kondo D, Kanazawa H, Narita I. Usefulness of a pleuroperitoneal shunt for treatment of refractory pleural effusion in a patient receiving maintenance hemodialysis. CEN Case Rep 2018; 7:189-194. [PMID: 29572611 DOI: 10.1007/s13730-018-0323-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Accepted: 03/17/2018] [Indexed: 11/26/2022] Open
Abstract
Refractory pleural effusion can be a life-threatening complication in patients receiving maintenance hemodialysis. We report successful treatment of refractory pleural effusion using a Denver® pleuroperitoneal shunt in one such patient. A 54-year-old Japanese man, who had previously undergone left nephrectomy, was admitted urgently to our department because of a high C-reactive protein (CRP) level, right pleural effusion, and right renal abscess. Because antibiotics proved ineffective and his general state was deteriorating, he underwent emergency insertion of a thoracic drainage tube and nephrectomy, and hemodialysis was started. Although his general state improved slowly thereafter, the pleural effusion, which was unilateral and transudative, remained refractory and therefore he needed to be on oxygenation. To control the massive pleural effusion, a pleuroperitoneal shunt was inserted. Thereafter, his respiratory condition became stable without oxygenation and he was discharged. His general condition has since been well. Although pleural effusion is a common complication of maintenance hemodialysis, few reports have documented the use of pleuroperitoneal shunt to control refractory pleural effusion. Pleuroperitoneal shunt has been advocated as an effective and low-morbidity treatment for refractory pleural effusion, and its use for some patients with recurrent pleural effusion has also been reported, without any severe complications. In the present case, pleuroperitoneal shunt improved the patient's quality of life sufficiently to allow him to be discharged home without oxygenation. Pleuroperitoneal shunt should be considered a useful treatment option for hemodialysis patients with refractory pleural effusion.
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Affiliation(s)
- Masato Habuka
- Division of Clinical Nephrology and Rheumatology, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata city, Niigata, 950-1197, Japan.
| | - Toru Ito
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Yuta Yoshizawa
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Koji Matsuo
- Division of Nephrology, Itoigawa Sogo Hospital, Niigata, Japan
| | - Shuichi Murakami
- Division of Clinical Nephrology and Rheumatology, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata city, Niigata, 950-1197, Japan
| | - Daisuke Kondo
- Division of Clinical Nephrology and Rheumatology, Niigata City General Hospital, 463-7 Shumoku, Chuo-ku, Niigata city, Niigata, 950-1197, Japan
| | - Hiroshi Kanazawa
- Division of Cardiovascular Surgery, Niigata Minami Hospital, Niigata, Japan
| | - Ichiei Narita
- Division of Clinical Nephrology and Rheumatology, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
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Kumar S, Agarwal R, Bal A, Sharma K, Singh N, Aggarwal AN, Verma I, Rana SV, Jha V. Utility of adenosine deaminase (ADA), PCR & thoracoscopy in differentiating tuberculous & non-tuberculous pleural effusion complicating chronic kidney disease. Indian J Med Res 2016; 141:308-14. [PMID: 25963491 PMCID: PMC4442328 DOI: 10.4103/0971-5916.156609] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background & objectives: Pleural effusion is a common occurrence in patients with late-stage chronic kidney disease (CKD). In developing countries, many effusions remain undiagnosed after pleural fluid analysis (PFA) and patients are empirically treated with antitubercular therapy. The aim of this study was to evaluate the role of adenosine deaminase (ADA), nucleic acid amplification tests (NAAT) and medical thoracoscopy in distinguishing tubercular and non-tubercular aetiologies in exudative pleural effusions complicating CKD. Methods: Consecutive stage 4 and 5 CKD patients with pleural effusions underwent PFA including ADA and PCR [65 kDa gene; multiplex (IS6110, protein antigen b, MPB64)]. Patients with exudative pleural effusion undiagnosed after PFA underwent medical thoracoscopy. Results: All 107 patients underwent thoracocentesis with 45 and 62 patients diagnosed as transudative and exudative pleural effusions, respectively. Twenty six of the 62 patients underwent medical thoracoscopy. Tuberculous pleurisy was diagnosed in six while uraemic pleuritis was diagnosed in 20 subjects. The sensitivity and specificity of pleural fluid ADA, 65 kDa gene PCR, and multiplex PCR were 66.7 and 90 per cent, 100 and 50 per cent, and 100 and 100 per cent, respectively. Thoracoscopy was associated with five complications in three patients. Interpretation & conclusions: Uraemia remains the most common cause of pleural effusion in CKD even in high TB prevalence country. Multiplex PCR and thoracoscopy are useful investigations in the diagnostic work-up of pleural effusions complicating CKD while the sensitivity and/or specificity of ADA and 65 kDa gene PCR is poor.
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Affiliation(s)
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
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Park EJ, Park MA, Park MJ, Park SY, Lee SH. Corticosteroid Therapy for Refractory Uremic Pleurisy. EWHA MEDICAL JOURNAL 2016. [DOI: 10.12771/emj.2016.39.4.125] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Eun Ji Park
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Min A Park
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Myung Jae Park
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - So Young Park
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
| | - Seung Hyeun Lee
- Department of Internal Medicine, Kyung Hee University School of Medicine, Seoul, Korea
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Sasaki Y, Isegawa T, Shimabukuro A, Yonaha T, Yonaha H. Primary Effusion Lymphoma in an Elderly HIV-Negative Patient with Hemodialysis: Importance of Evaluation for Pleural Effusion in Patients Receiving Hemodialysis. CASE REPORTS IN NEPHROLOGY AND UROLOGY 2014; 4:95-102. [PMID: 24987405 PMCID: PMC4067712 DOI: 10.1159/000363223] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Pleural effusion is a ubiquitous complication in hemodialysis (HD) patients. Common etiologies of pleural effusion in this patient group are heart failure, volume overload, parapneumonic effusion, tuberculotic pleuritis, and uremic pleuritis. Although thoracentesis is a useful diagnostic method of pleural effusion, empirical reduction of the dry weight is often attempted without thoracentesis because pleural effusion is commonly caused by volume overload and responds to the dry-weight reduction. However, this empiricism has a risk of overlooking or delaying the diagnosis of potentially fatal etiologies that need specific treatments. We report an 86-year-old human immunodeficiency virus (HIV)-negative male on HD with primary effusion lymphoma (PEL), a large-cell non-Hodgkin lymphoma presenting with characteristic lymphomatous effusions in the absence of solid tumor masses, which is in association with human herpes virus 8 (HHV8) infection in immunocompromised individuals. The patient presented with left-sided pleural effusion. This is the first case report of PEL developing in a patient receiving HD. Thoracentesis and cytological analysis of the effusion was key to the diagnosis. We also review the literature regarding pleural effusion in HD patients. Further, we examine Kaposi's sarcoma herpes virus/HHV8-negative effusion-based lymphoma, a newly proposed distinct lymphoma that clinically and cytomorphologically resembles PEL, because it can be cured without chemotherapy. This report may arouse clinicians’ attention regarding the importance of evaluation for pleural effusion in HD patients, especially when the effusion or symptoms associated with pleural effusion are refractory to volume control.
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Affiliation(s)
- Yosuke Sasaki
- Department of Internal Medicine, Okinawa Yaeyama Hospital, Okinawa, Japan
| | - Takuya Isegawa
- Department of Internal Medicine, Okinawa Yaeyama Hospital, Okinawa, Japan
| | - Akira Shimabukuro
- Department of Internal Medicine, Okinawa Yaeyama Hospital, Okinawa, Japan
| | | | - Hiroyasu Yonaha
- Department of General Medicine, Okinawa Yaeyama Hospital, Okinawa, Japan
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Corbett RW, Ashby DR. Complication of diagnostic pleural aspiration: is it of value in hemodialysis patients? Hemodial Int 2014; 18:546-50. [PMID: 24393436 DOI: 10.1111/hdi.12130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Pleural effusions are common in hemodialysis patients and are associated with significant morbidity. Diagnostic pleural aspiration and subsequent biochemical analysis can be used to differentiate exudates and transudates. In particular, Light's criteria have been validated in the general population although their efficacy in hemodialysis patients is unclear. Furthermore, aspiration is not without risk; we report the case of a life-threatening thoracic bleed as a complication of diagnostic thoracocentesis in a hemodialysis patient, in whom a transudative effusion was misclassified according to Light's criteria. Retrospective examination of a further 22 aspirations in hemodialysis patients suggests that biochemical analysis of pleural fluid in this group is of limited value. Careful clinical and radiological assessment may be of greater value in determining individuals who may benefit from formal drainage, rather than diagnostic aspiration with its attendant risks.
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Affiliation(s)
- Richard W Corbett
- Imperial College and Renal Transplant Centre, Imperial College Healthcare NHS Trust, London, UK
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Doelken P, Huggins JT, Goldblatt M, Nietert P, Sahn SA. Effects of coexisting pneumonia and end-stage renal disease on pleural fluid analysis in patients with hydrostatic pleural effusion. Chest 2013; 143:1709-1716. [PMID: 23288037 DOI: 10.1378/chest.12-2221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND In individual patients, especially those who are hospitalized, several conditions often coexist that may be responsible for the development of a pleural effusion and may affect the pleural fluid analysis (PFA). The objective of this study was to investigate the effects of end-stage renal disease and pneumonia on PFA in patients with hydrostatic pleural effusion. METHODS In a retrospective analysis of 1,064 consecutive patients who underwent thoracentesis at a university hospital, cell counts and pleural fluid protein, lactate dehydrogenase, pH, and glucose levels were examined in those (n = 300) with clinical evidence of hydrostatic pleural effusion. RESULTS The 300 patients (28.1%) with pleural effusions had congestive heart failure (CHF), circulatory overload (CO), or both. Expert consensus was achieved in 66 (22%) for CHF as the sole diagnosis (SCHF), 30 (10%) for CHF and coexisting pneumonia (PCHF), and 26 (8.7%) for end-stage renal disease (ESRD) with coexisting CO or CHF. The remaining 178 patients were excluded because of complicating conditions. There were minor, but statistically significant differences in pleural fluid/serum protein ratios in patients with ESRD with coexisting CO or CHF compared with SCHF. Compared with SCHF, there were statistically significant tendencies for higher protein and lactate dehydrogenase concentrations and lower pH levels in those with PCHF. The total nucleated cell count and the absolute neutrophil count were significantly higher in PCHF. CONCLUSIONS ESRD in patients with hydrostatic pleural effusions has a minimal effect on the PFA. Coexisting pneumonia most often results in an exudative effusion in patients with CHF.
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Affiliation(s)
- Peter Doelken
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY.
| | - John T Huggins
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC
| | | | - Paul Nietert
- Division of Biostatistics and Epidemiology, Medical University of South Carolina, Charleston, SC
| | - Steven A Sahn
- Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Medical University of South Carolina, Charleston, SC
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