Bilateral Pleural Effusion in Continuous Ambulatory Peritoneal Dialysis Managed by Vats Pleurodesis

Abstract

Pleuroperitoneal leak as a cause of pleural effusions in peritoneal dialysis is a rare but important complication to consider in continuous ambulatory peritoneal dialysis (CAPD) patients presenting with recurrent progressive dyspnoea. Generally, these effusions are unilateral and right-sided, resulting in shortness of breath and reduced ultrafiltration volume, which are initially managed by peritoneal rest. We describe a case of bilateral pleural effusions in a 57-year-old female on chronic CAPD who developed recurrent progressive dyspnoea but maintained adequate dialysis output. A chest radiograph revealed bilateral pleural effusions with high glucose content, and scintigraphy confirmed the existence of a definite pleuroperitoneal communication. She was managed by temporary substitution to haemodialysis, followed by suturing of the shunt and successful video-assisted thoracoscopic surgery (VATS) pleurodesis with an aldehyde-based surgical glue. Unexplained recurring dyspnoea in chronic CAPD should raise the suspicion of a possible pleuroperitoneal leak, even in patients without an apparent loss of ultrafiltration. Pleurodesis using an aldehyde-based adhesive was effective and tolerated well by our patient and may be considered in managing cases of recurrent pleural effusion.

Learning points: Recurrent dyspnoea in a chronic peritoneal dialysis patient should raise the diagnosis of a possible pleuroperitoneal leak, even if no apparent loss of ultrafiltration was observed.Minimally invasive surgical pleurodesis using surgical adhesive can be considered in cases of refractory pleuroperitoneal leak.

Keywords: Pleural effusion; peritoneal dialysis; pleurodesis; pleuroperitoneal leak; surgical adhesive.

Figure 1

Resolution of pleural effusion as shown on chest X-ray. A) Chest X-ray on admission demonstrating massive right hydrothorax and minimal left pleural effusion, and B) follow-up chest X-ray 2 months postsurgical intervention.

Figure 2

Peritoneal scintigraphy demonstrated extravasation of dialysate containing radioactive ^99mTc-pertechnetate into bilateral pleural cavities.

Figure 3

A) and B) VATS revealed a 1 × 2 mm circular tear at the posterolateral diaphragm, C) suture of the pleuroperitoneal communication, and D) pleurodesis with an aldehyde-based surgical glue.