Unilateral pleural effusion in chronic renal insufficiency: A clinician’s challenge

Abstract

hronic kidney disease (CKD) is a condition that presents usually with fluid overload. Pleural disease is a common problem in patients with chronic renal insufficiency which may be attributed to many etiologies, including congestive heart failure, infection, the presence of diseases associated with renal and pleural manifestations (e.g. systemic lupus in erythematosus), uremic pericarditis, malignancies, and pulmonary embolism. Unilateral pleural effusion is a diagnostic challenge in CKD patients. Uremic pleuritis results from an unknown putative agent, and therefore, uremic pleuritis is a diagnosis of exclusion [1]. CASE REPORTA 66-year-old male presented to us with a complaint of shortness of breath for 4 days. It was not associated with chest pain, decreased urine output, vomiting, altered sensorium, fever, palpitations, joint pain, cough with sputum, night sweats, and weight loss. There was no history of connective tissue disease such as rheumatoid arthritis (RA). The patient is a known case of type 2 diabetes (for 22 years), hypertension (for 22 years), and CKD (3 years). He was on tab. amlodipine 10 mg OD, prazosin 10 mg OD, torsemide 20 mg BD, and linagliptin 5 mg OD. For the past 3 years, the patient was on regular medication and his renal functions remained stable, not requiring renal replacement therapy.On admission, blood pressure was 160/100 mmHg, pulse rate was 110/min, and tachypneic at rest with a saturation of 85% at room air. On general physical examination, the patient was pale and having bilateral pedal edema. Icterus, clubbing, cyanosis, and jugular venous distension were absent. Respiratory system examination revealed tracheal deviation towards the right, dull percussion notes, and reduced air entry on auscultation over the left lung field. Cardiac examination was unremarkable.Renal function tests performed 6 months back revealed creatinine 5.3 mg/dl and urea 152 mg/dl with estimated glomerular filtration rate (eGFR) of 12 ml/min/1.73 m 2 which were found worsened on this admission with creatinine 6.4 and urea 201 with eGFR 9 ml/min/1.73 m 2 . Complete hemogram revealed hemoglobin 7.1 g/dl microcytic hypochromic, total leukocyte count of 6800/mm 3 , and platelet count of 240,000/mm 3 . Liver function tests were unremarkable with albumin of 3.6 g/dl. Uric acid was 9.6 mg/dl, calcium was 7.9 mg/dl, phosphorus was 8.9 mg/dl, and normal arterial blood gas analysis. Erythrocyte sedimentation rate was 24 mm/h, Mantoux test was negative, and RA factor was negative. Digital chest X-ray revealed left-sided pleural effusion with right-sided tracheal shift with clear costophrenic angle on the right side (Fig. 1a).On thoracentesis, the pleural fluid was hemorrhagic, exudative with pleural fluid-to-serum protein ratio was 0.54(3.5/6.4), and the pleural fluid to serum lactate dehydrogenase ratio >0.6 (294/254) with lymphocytic predominance and adenosine deaminase of 9.1. No organisms were seen on Gram stain, no acid-fast bacilli were seen, and the cartridge-based nucleic acid amplification test was negative...