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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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Abstract
The causes of respiratory failure can be divided into two main groups: extrapulmonary and pulmonary. Extrapulmonary causes of respiratory failure include conditions that exclusively or primarily cause respiratory failure by their effect on structures other than the lungs (i.e., the extrapulmonary compartment). To place the topic of extrapulmonary respiratory failure into perspective, we briefly review normal and abnormal gas exchange and then examine how one can use this information to suspect or confirm the diagnosis of an extrapulmonary cause of respiratory failure. We then review the individual causes of extrapulmonary respiratory failure. These have been divided into two main functional categories: (1) those that involve a decrease in normal force generation, and (2) those that involve an increase in resistance to (bulk flow) ventilation. We then briefly consider the treatment of these disorders from a respiratory point of view.
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Affiliation(s)
- Melvin R. Pratter
- University of Massachusetts Medical School, Pulmonary Medicine Division, Worcester, MA 01605
| | - Richard S. Irwin
- University of Massachusetts Medical School, Pulmonary Medicine Division, Worcester, MA 01605
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Lee SY, Hong GY, Chung JG, Yang DH, Kim HJ. Refractory uraemic pleuropericarditis treated successfully with corticosteroid therapy. Clin Kidney J 2009; 2:473-5. [PMID: 25949383 PMCID: PMC4421331 DOI: 10.1093/ndtplus/sfp102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2009] [Accepted: 07/13/2009] [Indexed: 11/18/2022] Open
Abstract
Uraemic pleuritis and pericarditis are frequently observed in chronic renal failure patients and tend to improve with continued haemodialysis. However, certain cases have been reported that do not respond to continued haemodialysis alone. A 67-year-old female on long-term haemodialysis was diagnosed with uraemic pleuropericarditis and treated with intensive haemodialysis and given a non-steroidal anti-inflammatory drug to which she showed no response. We report a case of uraemic pleuropericarditis refractory to traditional therapy, which was treated successfully with corticosteroid therapy.
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Affiliation(s)
- So-Young Lee
- Department of Internal Medicine, College of Medicine , CHA University , Seongnam , Korea
| | - Gi-Youn Hong
- Department of Internal Medicine, College of Medicine , CHA University , Seongnam , Korea
| | - Jun Gu Chung
- Department of Internal Medicine, College of Medicine , CHA University , Seongnam , Korea
| | - Dong Ho Yang
- Department of Internal Medicine, College of Medicine , CHA University , Seongnam , Korea
| | - Hyung-Jong Kim
- Department of Internal Medicine, College of Medicine , CHA University , Seongnam , Korea
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Abstract
Pleural fibrosis can result from a variety of inflammatory processes. The response of the pleural mesothelial cell to injury and the ability to maintain its integrity are crucial in determining whether normal healing or pleural fibrosis occurs. The pleural mesothelial cell, various cytokines, and disordered fibrin turnover are involved in the pathogenesis of pleural fibrosis. The roles of these mediators in producing pleural fibrosis are examined. This article reviews the most common clinical conditions associated with the development of pleural fibrosis. Fibrothorax and trapped lung are two unique and uncommon consequences of pleural fibrosis. The management of pleural fibrosis, including fibrothorax and trapped lung, is discussed.
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Affiliation(s)
- Michael A Jantz
- Division of Pulmonary and Critical Care Medicine, University of Florida, 1600 SW Archer Road, Room M352, PO Box 100225, Gainesville, FL 32610-0225, USA.
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Affiliation(s)
- Abeer Al Harby
- Department of Medicine, Section of Pulmonary Medicine & Nephrology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Othman Al Furayh
- Department of Medicine, Section of Pulmonary Medicine & Nephrology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Fouad Al Dayel
- Department of Pathology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Abdullah Al Mobeireek
- Department of Medicine, Section of Pulmonary Medicine & Nephrology, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
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Abstract
The development of pleural fibrosis follows severe pleural space inflammation which is typically associated with an exudative pleural effusion. The response of the mesothelial cell to injury and its ability, along with the basement membrane, to maintain its integrity, is vital in determining whether there is normal healing or pleural fibrosis. The formation of a fibrinous intrapleural matrix is critical to the development of pleural fibrosis. This matrix is the result of disordered fibrin turnover, whereby fibrin formation is up-regulated and fibrin dissolution is down-regulated. Cytokines, such as TGF-beta and TNF-alpha, facilitate the fibrin matrix formation. A complete understanding of the pathogenesis of pleural fibrosis and why abnormal pleural space remodeling occurs in some and not in others, remains unknown. Clinically significant pleural fibrosis requires involvement of the visceral pleura. Isolated parietal pleural fibrosis, as with asbestos pleural plaques, does not cause restriction or respiratory impairment. The causes of visceral pleural fibrosis include asbestos-associated diffuse pleural thickening, coronary bypass graft surgery, pleural infection (including tuberculous pleurisy), drug-induced pleuritis, rheumatoid pleurisy, uraemic pleurisy, and haemothorax. Systemic and intrapleural corticosteroids administered during the initial presentation of rheumatoid pleurisy in small series may decrease the incidence of pleural fibrosis. Several randomised control trials using corticosteroids in tuberculous pleurisy have not shown efficacy in reducing residual pleural fibrosis. Decortication is effective in treating symptomatic patients regardless of the cause of pleural fibrosis as long as chronicity has been documented and significant underlying parenchymal disease has been excluded.
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Affiliation(s)
- John T Huggins
- Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology Medical University of South Carolina, Charleston, South Carolina 29425, USA.
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Affiliation(s)
- M Cohen
- Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC 29425, USA
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Jantz MA, Sahn SA. Pleural Disease in the Intensive Care Unit. J Intensive Care Med 2000. [DOI: 10.1046/j.1525-1489.2000.00063.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Jantz MA, Sahn SA. Pleural Disease in the Intensive Care Unit. J Intensive Care Med 2000. [DOI: 10.1177/088506660001500201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Pleural disease itself is an unusual cause for admission to the intensive care unit (ICU). Pleural complications of diseases and procedures in the ICU are common, however, and the impact on respiratory physiology is additive to that of the underlying cardiopulmonary disease. Pleural effusion and pneumothorax may be overlooked in the critically ill patient due to alterations in radiologic appearance in the supine patient. The development of a pneumothorax in a patient in the ICU represents a potentially life-threatening situation. This article reviews the etiologies, pathophysiology, and management of pleural effusion, pneumothorax, tension pneumothorax, and bronchopleural fistula in the critically ill patient. In addition, we review the potential complications of thoracentesis and chest tube thoracostomy, including re-expansion pulmonary edema.
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Affiliation(s)
- Michael A. Jantz
- From the Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC
| | - Steven A. Sahn
- From the Division of Pulmonary and Critical Care Medicine, Allergy and Clinical Immunology, Medical University of South Carolina, Charleston, SC
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Jarratt MJ, Sahn SA. Pleural effusions in hospitalized patients receiving long-term hemodialysis. Chest 1995; 108:470-4. [PMID: 7634886 DOI: 10.1378/chest.108.2.470] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
OBJECTIVE To determine the incidence, causes, and clinical features of pleural effusions in hospitalized patients receiving long-term hemodialysis. DESIGN Retrospective. PARTICIPANTS One hundred patients receiving hemodialysis for at least 3 months with pleural effusion hospitalized at the Medical University of South Carolina hospitals. RESULTS The incidence of pleural effusions in hospitalized patients receiving long-term hemodialysis was 21%. The mean (+/- SEM) age was 55 +/- 1.4 years and the male to female and black to white ratios were 3:2. Pleural effusions resulted from heart failure in 46% and nonheart failure causes in 54%. Uremic pleurisy (n = 16), parapneumonic effusion (n = 15), and atelectasis (n = 11) accounted for most of the nonheart failure causes of pleural effusions. Three of 15 (20%) parapneumonic effusions were empyemas. The presence of chest pain was not different in patients with parapneumonic effusions than in other patients with nonheart failure effusion (all p = NS) but was more frequent compared to those with heart failure (p = 0.006). Patients with parapneumonic effusions (p = 0.0006) and atelectasis (p = 0.003) were more likely to have unilateral pleural effusions than patients with heart failure. CONCLUSIONS Pleural effusions are common in hospitalized patients receiving chronic hemodialysis. Although heart failure was the most common cause, other diseases were responsible for most of the effusions. The presence of a unilateral effusion suggests a diagnosis other than heart failure, most commonly parapneumonic effusion or atelectasis and deserves prompt thoracentesis as these effusions often cannot be reliably differentiated clinically. The reduced humoral and cellular immunity, in addition to delay in diagnosis because of an attenuated clinical response, may explain the high rate of empyemas in this study population.
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Affiliation(s)
- M J Jarratt
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston 29425, USA
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Ettinger NA, Trulock EP. Pulmonary considerations of organ transplantation. Part I. THE AMERICAN REVIEW OF RESPIRATORY DISEASE 1991; 143:1386-405. [PMID: 2048827 DOI: 10.1164/ajrccm/143.6.1386] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- N A Ettinger
- Respiratory and Critical Care Division, Washington University School of Medicine, St. Louis, Missouri
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Affiliation(s)
- S A Sahn
- Division of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston
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Buchanan DR, Johnston ID, Kerr IH, Hetzel MR, Corrin B, Turner-Warwick M. Cryptogenic bilateral fibrosing pleuritis. BRITISH JOURNAL OF DISEASES OF THE CHEST 1988; 82:186-93. [PMID: 3166932 DOI: 10.1016/0007-0971(88)90042-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
We describe four patients with bilateral pleural effusions progressing to diffuse pleural thickening for which we have been unable to find any evidence of an infective, embolic or occupational aetiology. In order to avoid confusion with diffuse pleural thickening attributable to asbestos-related disease, the term cryptogenic bilateral fibrosing pleuritis is suggested. The patients differed from those with pleural shadowing due to asbestos in that none of them gave a history of asbestos exposure, all were ill, presented with chest pain which was not always pleuritic in character, and had dyspnoea, cough or malaise. They had pleural effusions of variable size, pleural shadowing radiographically and raised sedimentation rates. Computed tomography revealed bilateral extensive pleural thickening in all cases. All four were HLA B44 positive. Histology showed that in all cases the pleura was thickened by fibrous tissue. Both layers were affected and the pleural space was often obliterated. Otherwise the pleural surface was covered by organizing fibrin. Focal collections of lymphocytes were often present when the fibrous tissue abutted on the subpleural fat. No asbestos bodies were seen in any of the cases and in one patient electron microscopic fibre counts showed no excess of asbestos. Pleural decortication was successful in three patients. In one of these, contralateral disease was successfully controlled with corticosteroids, but the fourth patient has not improved on corticosteroids.
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Abstract
Pleural abnormalities of uremia have been recognized for many years but have been given little attention despite their high incidence. Mechanisms underlying pleural effusion relate to filtration forces across subpleural capillaries and lymphatic absorption, either of which can be abnormal in patients with renal failure. Uremic patients have increased susceptibility to many causes of pleural exudate. In addition, a specific uremic pleuritis has been characterized as necrotizing fibrinous sterile exudate that is often hemorrhagic. Spontaneous remission, often with recurrences, or constrictive pleural thickening requiring surgical decortication may occur. Neither the pathogenesis nor the appropriate treatment of uremic pleuritis has been established definitively.
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