Abstract Introduction Throughout the United States, changes in population demographics, such as an aging population and increased incidence of diabetes mellitus, as well as decreased mortality have led to an increase in the number of patients living with end stage renal disease (ESRD). Due to factors such as decreased cost and convenience for patients, peritoneal dialysis may often be a preferred method of renal replacement compared to in-center hemodialysis. Significant complications can arise from peritoneal dialysis, however, and a high index of suspicion is necessary to recognize these complications early. Here we describe a case of a pleuroperitoneal leak leading to significant respiratory distress in a patient who started peritoneal dialysis two weeks prior. Case Description A 53-year-old man with a history of congestive heart failure, ESRD, and type 1 diabetes mellitus presented with one day of progressively worsening dyspnea and several days of increasing lower-extremity swelling with a reported 5-10 pound weight gain. The patient recently transitioned from hemodialysis to peritoneal dialysis two weeks before this presentation. Upon arrival he was afebrile with oxygen saturation later dropping to 88% on 5 liters, prompting escalation to high-flow nasal cannula. On physical examination, he was alert but in mild respiratory distress, with breath sounds markedly decreased over the right lower lung field, and bilateral lower-extremity edema. An initial chest X-ray demonstrated a new moderate right-sided pleural effusion, with a repeat X-ray showing near complete opacity of the right lung as shown below. The patient underwent ultrasound-guided thoracentesis, which yielded 1.6 liters of clear fluid, followed by chest tube placement for continued drainage with a total output of approximately 5 liters. Pleural fluid analysis revealed a transudative effusion by Light’s criteria, with glucose concentration of 541 mg/dL—markedly higher than serum glucose—strongly suggestive of a pleuroperitoneal leak. Following thoracentesis, the patient’s oxygenation improved significantly, and his oxygen requirement decreased to 3 liters per minute by nasal cannula, with near resolution of the effusion on repeat chest X-ray. Peritoneal dialysis was discontinued, and he was transitioned back to hemodialysis for better volume control and ultrafiltration. Discussion This case highlights the importance of maintaining a high index of suspicion for pleuroperitoneal leaks in peritoneal dialysis patients presenting with new-onset pleural effusion, particularly soon after the initiation or transition of dialysis modality. Early diagnosis through pleural fluid analysis, timely intervention, and multidisciplinary collaboration between nephrology, pulmonology, and radiology are essential to achieving favorable outcomes. This abstract is funded by: None
Mancini et al. (Fri,) studied this question.