You are here

Article Text

Article menu

Download PDFPDF

Pleuroperitoneal leak in a peritoneal dialysis patient
Free
  1. Muhammad Asim1,2,
  2. Eiman Mohamed Hamid1
  1. 1Department of Medicine, Hamad Medical Corporation, Doha, Qatar
  2. 2Department of Clinical Medicine, Weil Cornell Medical College in Qatar, Doha, Qatar
  1. Correspondence to Dr Muhammad Asim, mua2002{at}qatar-med.cornell.edu

https://doi.org/10.1136/bcr-2013-200130

Statistics from Altmetric.com

    Request Permissions

    If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

    Description

    An abnormal communication between peritoneum and pleural space might exist as a result of congenital or acquired defect in the diaphragmatic muscle fibres/connective tissue.1 In the presence of such a communication in a patient on continuous ambulatory peritoneal dialysis (CAPD), any undue increase in intra-abdominal pressure secondary to high dwell volumes, chronic cough or straining can lead to a higher pleuroperitoneal pressure gradient and thus facilitate translocation of dialysate into the pleural space.

    A patient with end-stage-renal-disease on CAPD presented with exertional dyspnoea. Physical examination and a chest X-ray (CXR) confirmed left pleural effusion. Aspirated pleural fluid was classified as a transudate based on its alkaline pH, low protein content and low lactic dehydrogenase level. A striking feature of the pleural fluid was its very high glucose concentration as compared with blood glucose. This was due to the presence of dextrose containing dialysate that had translocated from the peritoneal cavity into the pleural space via an anatomical defect in the diaphragm. Isotopic peritoneography (figure 1) using Tc-99 DTPA demonstrated prompt reflux of the tracer in the left pleural space substantiating the presence of a pleuroperitoneal communication.

    Figure 1
    Figure 1

    Isotopic peritoneography (posterior views): serial scintigraphic views obtained after instillation of Tc-99 DTPA mixed dialysate into the peritoneal cavity via the peritoneal catheter. Initially, diffuse activity is seen only in the abdominal cavity (0 min frame) but later on, progressive increase in radiotracer activity is demonstrated in left pleural space (black arrows) signifying reflux of tracer material via the pleuroperitoneal communication.

    The peritoneal fluid was drained out, CAPD was discontinued and the patient was switched to haemodialysis. A follow-up CXR 2 weeks later showed complete resolution of pleural effusion. The patient preferred to stay on haemodialysis and therefore reintroduction of CAPD/intervention for pleuroperitoneal defect was not pursued.

    Learning points

    • Pleuroperitoneal leak should always be considered in the differential diagnosis of a pleural effusion developing in a patient on continuous ambulatory peritoneal dialysis.

    • Isotopic peritoneography can demonstrate radioisotope tracer refluxing into the pleural space.

    • Measurement of pleural fluid glucose is a simple and reliable means for diagnosing pleuroperitoneal leak.2

    References

    1. ↵
      1. García Ramón RA,
      2. Carrasco M
      . Hydrothorax in peritoneal dialysis. Perit Dial Int 1998;2013:5–10.
      OpenUrl
    2. ↵
      1. Chow KM,
      2. Szeto CC,
      3. Wong TYH,
      4. et al
      . Hydrothorax complicating peritoneal dialysis: diagnostic value of glucose concentration in pleural fluid aspirate. Perit Dial Int 2002;2013:525–8.
      OpenUrl
    View Abstract

    Footnotes

    • Contributors MA participated in acquisition and formatting of image, critical revision and final approval of the manuscript. EMH participated in acquisition of clinical data, initial draft of the article and final approval of the manuscript.

    • Competing interests None.

    • Patient consent Obtained.

    • Provenance and peer review Not commissioned; externally peer reviewed.