Hydrothorax and end-stage chronic renal failure

Complications of Peritoneal Dialysis Part I: Mechanical Complications

Peritoneal dialysis (PD) is a form of KRT that offers flexibility and autonomy to patients with ESKD. It is associated with lower costs compared with hemodialysis in many countries. However, it can be associated with unexpected interruptions to or discontinuation of therapy. Timely diagnosis and resolution are required to minimize preventable modality change to hemodialysis. This review covers mechanical complications, including leaks, PD hydrothorax, hernias, dialysate flow problems, PD-related pain, and changes in respiratory mechanics. Most mechanical complications occur early, either as a result of PD catheter insertion or the introduction of dialysate and consequent increased intra-abdominal pressure. Late mechanical complications can also occur and may require different treatment.

Successful treatment of pleuroperitoneal communication with pleurodesis using autologous blood in a patient with severe heart failure undergoing peritoneal dialysis: a case report and brief literature review

Background

Pleuroperitoneal communication is a potential complication of peritoneal dialysis (PD). Of the various treatment strategies for pleuroperitoneal communication, successful treatment with pleurodesis using autologous blood has rarely been reported.

Case presentation

A 58-year-old man with end-stage kidney disease secondary to diabetic nephropathy and severe heart failure was placed on PD. He developed right-sided hydrothorax after the commencement of PD. Technetium-99m macro-aggregated human serum albumin peritoneal scintigraphy revealed pleuroperitoneal communication. PD was temporarily discontinued and substituted with hemodialysis. Subsequently, the levels of pleural fluid decreased. However, the resumption of PD exacerbated the hydrothorax. After thoracentesis, 50 mL of autologous blood was instilled into the right pleural cavity. There were no complications related to the procedure. PD was reinitiated 5 days after pleurodesis. Repeated chest X-rays did not depict any evidence of recurrent hydrothorax over the subsequent 10 months.

Conclusions

Pleurodesis using autologous blood was effective for pleuroperitoneal communication and was evidently safe in our patient. It should be considered in patients with severe heart failure since it is minimally invasive.

Video-assisted thoracic surgery for pleuroperitoneal communication

Background

Hydrothorax due to pleuroperitoneal communication (PPC) is a rare complication of continuous ambulatory peritoneal dialysis (CAPD). Approximately 50% of the patients need to convert to hemodialysis.

Case presentation

A 65-year-old man with chronic renal failure due to membranoproliferative glomerulonephritis underwent CAPD. Seven months after starting CAPD, a chest X-ray showed a right hydrothorax. For performing radioscintigraphy, ^99mTc-macro-aggregated albumin was administered into the peritoneal cavity with dialysate, and a leakage point of the dialysate into the right pleural cavity was detected. He was diagnosed with PPC and underwent video-assisted thoracic surgery (VATS). The hole was closed by direct suturing and reinforced by a pedicled latissimus dorsi muscle flap (LDM). The patient resumed CAPD 7 weeks later and had no recurrence of the right hydrothorax.

Conclusions

VATS was a useful method for treating PPC. A pedicled LDM flap is an effective material for preventing the recurrence of PPC.

Peritoneal-Pleural Leaks Demonstrated by CT Peritoneography

Introduction

Acute hydrothorax is an uncommon complication of peritoneal dialysis (PD). Currently, there is no specific diagnostic method. Although it is not a life-threatening complication, hydrothorax often requires interrupting or quitting PD. Misdiagnosis often leads to more serious consequences.

Case Presentation

A 49-year-old woman (height 163 cm, weight 58 kg, BMI 21.82), who started PD 3 months previously, suddenly presented with acute dyspnea and a right pleural effusion. Blood routine examination, serum albumin and a series of laboratory tests were immediately performed. Except for the serum creatinine, all of the other tests were within normal range. Thoracentesis was performed to obtain pleural fluid specimens; there was also no evidence of a tumor or inflammation. Congestive heart failure, infection and hypoalbuminemia were excluded as well. Because PD-associated pleural leakage was suspected, computerized tomography (CT) peritoneography was performed next. The first CT scan showed that the CT value of pleural effusion was 6 Hounsfield units (HU). On the evening of the same day, 100 ml ionic contrast medium was mixed with 2 l dialysate and infused into the peritoneal cavity. The next morning, a CT scan was performed again. The CT value of pleural effusion at the same site increased to 40 HU. At the end, pleural leakage was clearly diagnosed. Subsequently, she received temporary hemodialysis and a small dose of automated PD. After 3 months, she successfully returned to PD without any recurrence of hydrothorax.

Conclusion

Although similar case reports are not rare, this report provided a simple and effective method for diagnosing pleural leakage. Furthermore, noninvasive treatment of pleural effusion will also get a satisfactory outcome.

Peritoneal dialysis in renal replacement therapy for patients with acute kidney injury

Peritoneal dialysis (PD) was the first modality used for renal replacement therapy (RRT) of patients with acute kidney injury (AKI) because of its inherent advantages as compared to Hemodialysis. It provides the nephrologist with nonvascular alternative for renal replacement therapy. It is an inexpensive modality in developing countries and does not require highly trained staff or a complex apparatus. Systemic anticoagulation is not needed, and it can be easily initiated. It can be used as continuous or intermittent procedure and, due to slow fluid and solute removal, helps maintain hemodynamic stability especially in patients admitted to the intensive care unit. PD has been successfully used in AKI involving patients with hemodynamic instability, those at risk of bleeding, and infants and children with AKI or circulatory failure. Newer continuous renal replacement therapies (CRRTs) are being increasingly used in renal replacement therapy of AKI with less use of PD. Results of studies comparing newer modalities of CRRT versus acute peritoneal dialysis have been conflicting. PD is the modality of choice in renal replacement therapy in pediatric patients and in patients with AKI in developing countries.

Acute hydrothorax complicating peritoneal dialysis: a case report

INTRODUCTION

Acute hydrothorax is an uncommon but a well-recognized complication of peritoneal dialysis. No single test is definitive for diagnosis. Although it is not a life-threatening condition, hydrothorax often requires abandonment of peritoneal dialysis. Delay in diagnosis can lead to worsening of the clinical status.

CASE PRESENTATION

A 33-year-old Caucasian woman with lupus, who was successfully treated with temporary peritoneal dialysis 17 years previously, presented with acute dyspnea and a right pleural effusion after recommencing peritoneal dialysis. Investigations eliminated infective, cardiac, and primary respiratory causes. Peritoneal dialysis-related hydrothorax was suggested by biochemistry, and a pleuroperitoneal leak was definitively confirmed by using a Tc-99 m DTPA (diethylene triamine penta-acetic acid) scintigraphy scan. Subsequently, she underwent video-assisted thoracoscopy-guided talc pleurodesis and was able to return successfully to peritoneal dialysis.

CONCLUSION

Although our case is not the first report that describes the occurrence of acute hydrothorax in peritoneal dialysis, it is an important condition to recognize for the wider general medical community. Furthermore, this case demonstrates that peritoneal dialysis can be continued with a hydrothorax, provided the underlying cause can be corrected. We review the literature pertaining to the utility and reliability of different diagnostic approaches to hydrothorax.

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).

Pathogenesis and management of hydrothorax complicating peritoneal dialysis

PURPOSE OF REVIEW

Hydrothorax complicating continuous ambulatory peritoneal dialysis (CAPD) appears in approximately 2% of all patients. Recent advances in minimally invasive surgery have revolutionized the treatment strategy of this condition.

RECENT FINDINGS

Hydrothorax in CAPD is most commonly secondary to a pleuro-peritoneal communication. Thoracocentesis with biochemical analysis of pleural fluid is the first-line investigation. In uncertain cases, or when there is a clinical need to demonstrate the anatomy of the communication, an imaging approach such as peritoneal scintigraphy is required. Cessation of peritoneal dialysis is indicated if diagnosis of the complication is confirmed. For half of the cases, a conservative approach allows reinstitution of CAPD, presumably because of spontaneous resolution of the leakage. A small-volume exchange is a feasible alternative for children. In patients who failed conservative treatment, video-assisted thoracoscopic pleurodesis or diaphragmatic repair or both allows most of them to continue with CAPD. Chemical pleurodesis is probably indicated for those who failed conservative treatment in centers without video-assisted thoracoscopic support. Currently, only a minority of patients will require open thoracotomy.

SUMMARY

Once hydrothorax secondary to pleuro-peritoneal communication is confirmed in CAPD patients, temporary cessation of peritoneal dialysis remains the first-line treatment. Current evidence shows that video-assisted thoracoscopic pleurodesis or repair should be the treatment of choice in patients who failed conservative management.

Management options for hydrothorax complicating peritoneal dialysis

Hydrothorax as a result of pleuroperitoneal communication occurs in approximately 2% of continuous ambulatory peritoneal dialysis (CAPD) patients. Although our understanding of its mechanisms is incomplete, it is apparent that the key to successful therapy is obliteration of a transdiaphragmatic route of dialysate leakage (pleuroperitoneal communication), possibly coupled with reduction of intra-abdominal pressure. This review corroborated the findings from 10 major population-based case series in which 60 of the 104 cases (58%) were able to resume long-term peritoneal dialysis (PD). Temporary interruption of PD alone was successful in half of them. As compared to this conservative approach, as well as chemical pleurodesis via intercostal chest drain, video-assisted thoracoscopic intervention (including direct pleurodesis and diaphragmatic repair) has shown a promising role. Efficacy of thoracoscopic treatment has been confirmed by several case series from various centers and the demonstration of a success rate in excess of 90%. With accumulating experience using the thoracoscopic technique, it remains to be seen whether this mode of treatment will obviate the traditional closed pleurodesis.

Thoracic complications of peritoneal dialysis

Approximately 20% of the 100,000 patients in the United States currently undergoing dialysis therapy for end-stage renal disease use the technique of peritoneal dialysis. We present a patient on peritoneal dialysis who developed a large posterior mediastinal mass, which on surgical exploration was found to be a paraesophageal hernia sac filled with omentum and dialysis fluid. We use this case as an introduction to review the thoracic complications of peritoneal dialysis.