Hydrothorax as a Complication of Pediatric Peritoneal Dialysis

Hydrothorax is a known complication of peritoneal dialysis (PD) but there is very little in the pediatric literature concerning this complication.

From 1982 to 1984 seven of 29 of our patients who underwent peritoneal dialysis, developed pleural effusions as a complication of PD. These patients varied in respect to age, technique and duration of PD. Four of the seven developed respiratory symptoms at the time when effusions were discovered, while the other three were recognized during evaluation of loss of ultrafiltration. Five of the seven had right-sided effusions, one had a left-sided effusion, and one had bilateral effusions. No technical factors could be identified as causative agents.

We have concluded that pediatric patients may be particularly likely to develop hydrothorax as a complication of peritoneal dialysis. This may present as a pulmonary emergency or as a subtle loss of ultrafiltration ability. The possibility of congenital potential communicating pathways seems more likely than any other single explanation for this phenomena.

Hydrothorax as a complication of peritoneal dialysis (PD) is reported chiefly in the adult PD literature. The first reports were associated with trauma but in most subsequent cases, there was no explanation.

We are aware of only two accounts of this complication in children covering a total of eight cases. Several of these may have been related to surgical trauma (1). However, in our own patient population, we observed seven who developed hydrothorax while on various forms of PD. Review of individual cases did not demonstrate common factors which would explain the hydrothorax. Thus, hydrothorax developed during PD in a significant number of infants over a short period and under a variety of clinical circumstances. This suggests the existence of potential anatomical channels which may open under a variety of circumstances.

Pathogenesis and management of hydrothorax complicating peritoneal dialysis

PURPOSE OF REVIEW

Hydrothorax complicating continuous ambulatory peritoneal dialysis (CAPD) appears in approximately 2% of all patients. Recent advances in minimally invasive surgery have revolutionized the treatment strategy of this condition.

RECENT FINDINGS

Hydrothorax in CAPD is most commonly secondary to a pleuro-peritoneal communication. Thoracocentesis with biochemical analysis of pleural fluid is the first-line investigation. In uncertain cases, or when there is a clinical need to demonstrate the anatomy of the communication, an imaging approach such as peritoneal scintigraphy is required. Cessation of peritoneal dialysis is indicated if diagnosis of the complication is confirmed. For half of the cases, a conservative approach allows reinstitution of CAPD, presumably because of spontaneous resolution of the leakage. A small-volume exchange is a feasible alternative for children. In patients who failed conservative treatment, video-assisted thoracoscopic pleurodesis or diaphragmatic repair or both allows most of them to continue with CAPD. Chemical pleurodesis is probably indicated for those who failed conservative treatment in centers without video-assisted thoracoscopic support. Currently, only a minority of patients will require open thoracotomy.

SUMMARY

Once hydrothorax secondary to pleuro-peritoneal communication is confirmed in CAPD patients, temporary cessation of peritoneal dialysis remains the first-line treatment. Current evidence shows that video-assisted thoracoscopic pleurodesis or repair should be the treatment of choice in patients who failed conservative management.

Management options for hydrothorax complicating peritoneal dialysis

Hydrothorax as a result of pleuroperitoneal communication occurs in approximately 2% of continuous ambulatory peritoneal dialysis (CAPD) patients. Although our understanding of its mechanisms is incomplete, it is apparent that the key to successful therapy is obliteration of a transdiaphragmatic route of dialysate leakage (pleuroperitoneal communication), possibly coupled with reduction of intra-abdominal pressure. This review corroborated the findings from 10 major population-based case series in which 60 of the 104 cases (58%) were able to resume long-term peritoneal dialysis (PD). Temporary interruption of PD alone was successful in half of them. As compared to this conservative approach, as well as chemical pleurodesis via intercostal chest drain, video-assisted thoracoscopic intervention (including direct pleurodesis and diaphragmatic repair) has shown a promising role. Efficacy of thoracoscopic treatment has been confirmed by several case series from various centers and the demonstration of a success rate in excess of 90%. With accumulating experience using the thoracoscopic technique, it remains to be seen whether this mode of treatment will obviate the traditional closed pleurodesis.

Urinothorax as a manifestation of nondilated obstructive uropathy following renal transplantation

A 12-year-old patient developed prolonged nondilated urinary obstruction and pleural effusion shortly after undergoing renal transplantation. Renal sonography, angiography, and isotope renography failed to identify an obstructive process. On the 18th postoperative day, pleural effusion was noted in the right hemithorax, and by day 24, increased perinephric fluid was observed on renal scan. Following a nephrostomy, the pleural effusion resolved and renal function improved remarkably. A ureterovesical junction obstruction and renal pelvis tear that were later discovered were repaired. Whenever a ureteral obstruction is suspected the diagnosis should be pursued vigorously, despite normal radiologic findings, especially in the presence of pleural effusion. Consideration of the possibility of urinothorax in such cases may obviate the need for lung biopsy.

Hydrothorax in continuous ambulatory peritoneal dialysis: successful treatment with intrapleural tetracycline and a review of the literature

Recurrent hydrothorax complicating peritoneal dialysis has been considered a contraindication to continuing peritoneal dialysis. In the continuous ambulatory peritoneal dialysis (CAPD) population this problem has generally required a change of dialytic modality. Talc poudrage has been attempted to ameliorate the problem but has met with limited success. We report a successful case of intrapleural instillation of tetracycline to induce a pleural symphysis and prevent recurrence of peritoneal dialysis-related hydrothorax in a patient who refused any alternative mode of dialysis. We also review the literature, pathophysiology, epidemiology, diagnosis, and management of this compromising problem.