Ramakrishna Karan N, Lowe Dhruv, Murthy Uma K
Internal Medicine, State University of New York Upstate Medical University, Syracuse, USA.
Gastroenterology, State University of New York Upstate Medical University, Syracuse, USA.
Cureus. 2019 Jan 7;11(1):e3839. doi: 10.7759/cureus.3839.
Hydrothorax is a rare complication of peritoneal dialysis occurring in about 2% of continuous ambulatory peritoneal dialysis (CAPD) patients. These effusions occur soon after the onset of dialysis and are usually right-sided. We describe an unusual case of late-onset, left-sided, and recurrent effusions in the setting of CAPD. A 67-year-old patient with end-stage renal disease on CAPD for the last three years was admitted to our hospital with acute hypoxic respiratory failure secondary to a left-sided effusion. Although previously asymptomatic, he had three admissions for bilateral (left predominant) effusions in the last year, all of which were found to be transudative on analysis. Therapeutic thoracentesis once again revealed a transudative effusion with an elevated pleural fluid-serum glucose gradient. On this occasion, pleuro-peritoneal scintigraphy with technetium-99m was performed, uncovering a communication between the peritoneal cavity and the left pleural cavity. The peritoneal dialysis was substituted with hemodialysis, and the patient showed an eventual resolution of left-sided effusions within 18 months. Hydrothorax in peritoneal dialysis is due to the transudation of fluid across congenital or acquired pleuro-peritoneal communications. Pleural fluid with protein content less than 3 g/dl, high glucose, and low lactate dehydrogenase (LDH) relative to blood, and the presence of both D and L isomers of lactic acid suggest a transdiaphragmatic leak. Early diagnosis via peritoneal scintigraphy and appropriate management can prevent significant morbidity and mortality.
胸腔积液是腹膜透析的一种罕见并发症，约2%的持续性非卧床腹膜透析（CAPD）患者会出现。这些积液在透析开始后不久就会出现，且通常在右侧。我们描述了一例CAPD患者出现迟发性、左侧复发性积液的不寻常病例。一名67岁的患者，终末期肾病，过去三年一直进行CAPD治疗，因左侧积液继发急性缺氧性呼吸衰竭入住我院。尽管此前无症状，但他在去年因双侧（以左侧为主）积液三次入院，所有积液经分析均为漏出液。治疗性胸腔穿刺再次显示为漏出液，且胸水-血清葡萄糖梯度升高。此次进行了99m锝胸膜-腹膜闪烁显像，发现腹膜腔与左侧胸膜腔之间存在交通。腹膜透析被血液透析替代，患者左侧积液最终在18个月内消退。腹膜透析中的胸腔积液是由于液体通过先天性或后天性胸膜-腹膜交通处渗出所致。蛋白质含量低于3g/dl、葡萄糖含量高、相对于血液乳酸脱氢酶（LDH）含量低，以及同时存在乳酸的D型和L型异构体的胸水提示存在经膈肌渗漏。通过腹膜闪烁显像早期诊断并进行适当处理可预防严重的发病和死亡。
