OBJECTIVE: To demonstrate an important differential diagnosis of unilateral pleural effusion in a peritoneal dialysis patient and to review the therapeutic options for pleuroperitoneal leak to enable patients to remain on continuous ambulatory peritoneal dialysis (CAPD).

STUDY DESIGN: Case report

SETTING: National Kidney and Transplant Institute

CASE SUMMARY: This is the case of a 57-year old female with end-atage renal disease (ESRD) secondary to diabetic nephropathy, with a previous myocardial Infarction, who was started on CAPD with the onset of uremia. Although her symptoms improved after several dialysis exchanges, she later had chest pain and progressive dyspnea. She developed a right-sided transudative pleural effusion, which recurred on resumption of peritoneal dialysis (PD). Persistently poor PD fluid drainage was noted despite a change of the PD catheter. The diagnosis of hydrothorax probably due to a pleuroperitoneal leak was confirmed by peritoneal scintigraphy. With the patient's poor cardiovascular status, it was preferable that she remain on PD. Video-assisted thoracoscopic surgery (VATS) was performed, which revealed around 6 small fenestrations on the diaphragmatic surface, covered by a thin membrane 1 to 3 millimeters in diameter. Talc poudrage was done to promote adherence of the parietal and visceral pleurae, preventing fluid reaccumulation in the peural space. PD was discontinued for 4 weeks to allow adherence of the pleurae. It was resumed using gradually increasing PD fluid dwell volumes without further recurrence of hydrothorax. The patient successfully remained on ,PD.

CONCLUSION: This is the first reported case in the Philippines using VATS and talc poudrage as treatment for hydrothorax due to a pleuroperitoneal leak in a PD patient. It is an effective form of therapy with very little associated morbidity. The presence of a pleuroperitoneal leak no longer necessitates the switch provides an option for to hemodialysis (HD). It patients to remain on PD. (Author)