Jin, Xin

Abstract INTRODUCTION While cardiac comorbidities or factors predisposing infection are common in patients with ESRD, one less common cause for pleural effusion in peritoneal dialysis (PD) patients is pleuroperitoneal communication. We present herein a case of a PD patient with large, right-sided pleural effusion one year after starting PD. CASE REPORT An 82-year-old female with ESRD managed on home continuous cycling peritoneal dialysis (CCPD) for 1 year presented to the Emergency Department (ED) with new-onset dyspnea. She recently completed a course of vancomycin for bacterial peritonitis secondary to PD catheter infection. She also reported that her home CCPD machine was not draining the fill amount in recent weeks. She was afebrile and hemodynamically stable on arrival. CT at the ED showed a large, right-sided pleural effusion. She underwent thoracentesis with pending fluid analysis, and experienced subsequent improvement in her dyspnea. She was then hospitalized and wished to continue PD over pursuing intermittent hemodialysis (iHD) while workup was pending, despite clinical suspicion for pleuroperitoneal fistula (PPF). She started inpatient CCPD, and drains following each dwell showed less than expected volumes with no additional output on manual drains. She reported worsening dyspnea the next morning, and bedside POCUS confirmed reaccumulation of her pleural effusion. Fluid analysis revealed a transudative pleural fluid profile, with pleural glucose of 583mg/dL and serum glucose of 80mg/dL. Given her recent peritonitis, suspicion was greatest for PPF. The patient was transitioned from PD to iHD to allow time for the suspected fistula to heal, and subsequent imaging obtained during her hospitalization did not show reaccumulation of her unilateral pleural effusion. DISCUSSION Pleuroperitoneal communication may occur due to congenital or acquired diaphagmatic defects, or insults such as the case in our patient with recent peritonitis. In fact, diaphragmatic blebs from age related degeneration and chronic increased intraabdominal pressure have been reported to cause hydrothorax in patients undergoing PD. Diagnosis of PD-associated pleural effusions is based on clinical suspicion, with pleural studies showing high pleural fluid to serum glucose gradient, and imaging commonly showing unilateral right-sided pleural effusions. Recent peritoneal dialysis with low drainage further supports PD as the etiology. Most cases of PD-associated pleural effusions occur soon after PD initiation, but cases occurring years after initiation have been reported. Management involves halting PD and thoracentesis for symptomatic relief. Patients may need transitioning to iHD indefinitely, or may resume PD after a pause if the cause of communication is reversible.