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Kidney Week

Abstract: PO1008

Unusual Cause of Recurrent Shortness of Breath in a Peritoneal Dialysis Patient

Session Information

  • Peritoneal Dialysis
    November 04, 2021 | Location: On-Demand, Virtual Only
    Abstract Time: 10:00 AM - 12:00 PM

Category: Dialysis

  • 702 Dialysis: Home Dialysis and Peritoneal Dialysis

Authors

  • Gupta, Sonali, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
  • Sambharia, Meenakshi, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
  • Noureddine, Lama A., The University of Iowa Hospitals and Clinics, Iowa City, Iowa, United States
Introduction

Pleuroperitoneal leak (PPL) is an unusual cause of recurrent pleural effusion in patients on peritoneal dialysis (PD). It is a rare complication and occur in less than 2% of cases. Diagnosis is challenging and requires high clinical suspicion and awareness of this life threatening complication. Pleural fluid to serum glucose ratio of >50 mg/dl is highly specific for detecting leak of high glucose dialysate into pleural cavity, however this needs to be interpreted in relation with the last dialysis session.

Case Description

A 72 year-old-female with history of end stage renal disease due to biopsy proven focal segmental glomerular sclerosis thought to be secondary to obesity started on CCPD one-month prior presented with worsening shortness of breath of 1 week duration. Workup was unremarkable except for chest X-ray that showed right side pleural effusion. A non-contrast CT chest did not show a diaphragmatic defect. She continued to have worsening SOB prompting an emergent thoracentesis that drained 1.6 L transudate pleural fluid. Pleural fluid to serum glucose gradient was normal at 5 mg/dl but pleural fluid to serum glucose ratio was >1. However, last PD session was 2 days prior to thoracentesis, which could explain this lower ratio. Due to inconclusive[NL1] results, it was decided to instill 300 ml gastrografin in 6L of 2.5% dialysate bags and repeat CT chest. It showed interval re-accumulation of high-density pleural effusion, suggesting trans-diaphragmatic communication. Cardiothoracic surgery was consulted for repair of diaphragmatic defect; however, patient opted for hemodialysis instead.

Discussion

It is important to maintain high clinical index of suspicion in PD patients presenting with hydrothorax. Although high pleural fluid to serum glucose gradient is specific for PPL, pleural to serum glucose ratio >1 is another index that should be considered in addition to post- gastrografin imaging or technetium 99 peritoneal scintigraphy, especially if the last dialysis session was not recent and could potentially alter the biochemical assay results as happened in our case Most cases of PPL occur soon after PD initiation, common on right side. For those who wish to continue PD, surgical repair is often required while transitioning to HD temporarily or doing low volume recumbent PD. Some case series have noted the defect to close spontaneously after holding PD.