Disorders of the Pleura: Student/Resident Case Report Poster - Disorders of the Pleura |

Chronic Pleural Effusions Secondary to Peritoneal Dialysis FREE TO VIEW

Kunal Chawla, MD; Amish Shah, MD; Leena Pawar, MD; Kristine Soltanpour, DO; Samana Zaidi, MD
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SUNY Upstate Medical University, Syracuse, NY

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):587A. doi:10.1016/j.chest.2016.08.676
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SESSION TITLE: Student/Resident Case Report Poster - Disorders of the Pleura

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: A rare but well-established complication of peritoneal dialysis (PD) is hydrothorax, affecting 2% of people undergoing PD. These effusions are thought to be secondary to congenital diaphragmatic defects (more common on the right side) but may also be secondary to the increased intra-abdominal pressures from PD. When suspected, the first line investigation is chemical analysis of the pleural fluid which is expected to reveal a glucose gradient of more than 50mg/dL. Although usually sufficient to confirm a pleura-peritoneal communication, further investigation may be required to establish the diagnosis.

CASE PRESENTATION: A 67 YO male with PMHx of end stage renal disease on PD since 2013, coronary artery disease, diabetes, atrial fibrillation, and hypertension. Patient presented with complaints of shortness of breath and generalized weakness x 2 days. He was found to be hypoxic with O2 saturations in the 80s, his other vital signs were WNL. CXR revealed a large left sided pleural effusion. Patient had undergone thoracentesis three times in the past for recurrent effusions however the cause of his effusions was never identified. On this instance, thoracentesis was performed and workup revealed a transudative fluid with a glucose gradient of 14 mg/dL. All other fluid and serum studies returned within acceptable limits. Suspicion of a pleura-peritoneal communication was low because of the low glucose gradient in the peritoneal fluid as well as the fact that this was a left sided effusion. Nonetheless, peritoneal scintigraphy was conducted and demonstrated a pleuro-peritoneal communication. Patient was transitioned to hemodialysis and achieved complete resolution of his symptoms.

DISCUSSION: In patient’s undergoing PD, special consideration must be given to the possibility of a pleura-peritoneal communication. D-lactate levels and icodextrin levels on a pleural fluid sample can aid in diagnosis and a glucose gradient of >50mg/DL has a sensitivity and specificity of 100%. Although less common, left sided pleural effusions and pleural effusions with a low glucose gradient can still be secondary to PD and suspicion of a pleura-peritoneal communication must remain high. Suspected mechanism for a low glucose gradient is believed to be secondary to reabsorption by the pleural mesothelium. Confirmatory testing via peritoneal scintigraphy should be done to establish a diagnosis. Once identified, discontinuation of PD for up to 4-6 months may be effective in up to 50% of patients. If pleural effusions recur after re-initiation of PD, pleurodesis can be successful in up to 90% of patients.

CONCLUSIONS: Peritoneal scintigraphy should be conducted in any patient undergoing PD with an unexplained pleural effusion.

Reference #1: Sweet hydrothorax complicating chronic peritoneal dialysis Smolin, B. et al. Eur Journ. Intern Med. 2006;17(8) 583-584

Reference #2: Pathogenesis and management of hydrothorax complicating peritoneal dialysis C.C. Szeto, K.M. Chow. Curr Opin Pulm Med. 2004;10(4)314-319

DISCLOSURE: The following authors have nothing to disclose: Kunal Chawla, Amish Shah, Leena Pawar, Kristine Soltanpour, Samana Zaidi

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