Pleuroperitoneal Leak as an Uncommon Cause of Pleural Effusion in Peritoneal Dialysis: A Case Report and Literature Review

Abstract

Pleural effusions are frequently seen in patients on dialysis. A pleuroperitoneal leak or communication is a rare but important cause of pleural effusion in patients on peritoneal dialysis. This diagnosis can be made with a combination of biochemical tests and radiological modalities, in the absence of a gold standard diagnostic test. In addition to thoracocentesis, treatment often involves cessation of peritoneal dialysis and transition to hemodialysis. We describe a case of an 80-year-old man who presented with unilateral right-sided pleural effusion. He underwent therapeutic thoracocentesis and was subsequently diagnosed with a pleuroperitoneal leak through pleural fluid analysis. Peritoneal dialysis was ceased, and he transitioned temporarily to hemodialysis. He was subsequently treated with talc pleurodesis and successfully recommenced on peritoneal dialysis at six weeks after operation. In our report, we also review diagnostic imaging modalities, as well as advantages and disadvantages of each modality. A pleuroperitoneal leak is a rare but important complication of peritoneal dialysis and needs consideration in any patient on peritoneal dialysis presenting with unilateral pleural effusion.

Hydrothorax with Atypical Features as a Complication of Peritoneal Dialysis: A Case Report and Literature Review

“…6,8 In a study of 50 patients with PD-related effusions, 88% of cases were right-sided, likely due to the protective effects of the heart's location on the left diaphragm. 7 This case demonstrates an atypical presentation of an unusual complication, as the patient's hydrothorax presented with non-specific symptoms and was delayed, occurring several months after her PD therapy start date.…”

“…5,6 The pathophysiology of hydrothorax in peritoneal dialysis patients is commonly linked to congenital communications, diaphragmatic hernias, and fistulas, or acquired defects of subdiaphragmatic lymphatics, which serve as channels for the pleuroperitoneal leak. 7 Hydrothorax dependent on diaphragmatic defects, is usually expected to appear within one month of initiating PD therapy and predominantly occur on the right side. 6,8 In a study of 50 patients with PD-related effusions, 88% of cases were right-sided, likely due to the protective effects of the heart's location on the left diaphragm.…”

“…21 The typical course of management involves withholding PD with transition to HD to allow for a closure of the peritoneal defect. 7 The ideal duration for the rest period is unknown. A number of cases have shown that reinstating treatment with low-volume PD is possible after undergoing two to six weeks of peritoneal resting.…”

Delayed pleuroperitoneal leak in an otherwise uncomplicated course of peritoneal dialysis

“…Pleural effusions are common in PD patients and can be life‐threatening—thus, the etiology should be promptly determined. Definitive diagnosis of pleuroperitoneal leaks often relies on both biochemical and radiological assessment 4 . While some propose a PF to serum glucose gradient of at least 2.8 mmol/L is highly suggestive (not satisfied in this case), others postulate any PF to serum glucose ratio >1.0 is suggestive 1–3 .…”

SPECT/CT in Pleuroperitoneal Fistula Associated With Peritoneal Dialysis

“…Pleuroperitoneal fistula is a rare entity found in approximately 1.6% of patients with peritoneal dialysis. The pathophysiology is unknown, and it is usually associated with increased abdominal pressure 1–4 . Upon pleural fluid analysis, a transudate with elevated glucose concentration is found, and the patients present with acute dyspnea, cough, and decrease in the ultrafiltration rate 5–8 .…”