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Abstract: TH-PO349

Delayed "Sweet" Hydrothorax Associated with Peritoneal Dialysis

Session Information

  • Home Dialysis - I
    November 02, 2023 | Location: Exhibit Hall, Pennsylvania Convention Center
    Abstract Time: 10:00 AM - 12:00 PM

Category: Dialysis

  • 802 Dialysis: Home Dialysis and Peritoneal Dialysis


  • Natarajan, Hariharasudan, OU Health, Oklahoma City, Oklahoma, United States
  • Maryam, Bibi, OU Health, Oklahoma City, Oklahoma, United States
  • Ahmad, Zahid Bashir, OU Health, Oklahoma City, Oklahoma, United States

Hydrothorax in Peritoneal Dialysis (PD) patients is diagnostically challenging, often attributed to volume overload, uremic effusion, or parapneumonic effusion. A pleuro-peritoneal leak is a rare complication, usually presenting within 30 days of PD initiation, predominantly in females. We present a case of delayed pleuro-peritoneal leak three years after PD initiation.

Case Description

A 48-year-old man with end-stage renal disease from PLA2R-associated membranous nephropathy on automated peritoneal dialysis for 3 years presented with progressive dyspnea over 2 weeks. He had a recent admission for PD peritonitis 3 months ago. Examination revealed decreased breath sounds on the right side, crackles on the left lower lung fields, and pitting edema in both legs. A chest radiograph indicated a large right pleural effusion. Labs showed glucose of 69 mg/dL, elevated creatinine (21 mg/dL), elevated blood urea nitrogen (81 mg/dL), and elevated B-natriuretic peptide (1101 pg/mL), suggesting possible non-compliance with PD or PD failure. However, analysis of the pleural fluid sample revealed a protein concentration of 2.6 g/dL, creatinine of 22.1 mg/dL, glucose of 80 mg/dL, and lactate dehydrogenase of 162 IU/L, similar in composition to the dialysate fluid, consistent with a pleuro-peritoneal leak. Symptoms resolved upon discontinuing PD and switching to hemodialysis.


Pleuro-peritoneal leak, also known as "sweet hydrothorax," is a rare complication of PD and classically occurs within a month of initiating PD due to increased intra-abdominal pressure during PD fluid administration in patients with diaphragmatic defects. Our patient's delayed presentation is unique and may be linked to prior peritonitis and weakened diaphragmatic tissue. Prompt identification is crucial, as treating other causes of hydrothorax can worsen the leak. A pleural fluid to serum glucose ratio >1.0 and elevated creatinine levels close to dialysate composition indicate a leak, confirmable with Peritoneal Scintigraphy or CT/MR Peritoneography. Temporary transfer to hemodialysis often promotes healing, while chemical pleurodesis, surgical repair, or permanent transfer to hemodialysis are options if conservative measures fail. Our case highlights the possibility of delayed presentation after peritonitis and underscores the importance of timely identification.