Traumatic pleural leak in peritoneal dialysis.

Sir, Hydrothorax is a serious, although usually not life-threatening, complication of peritoneal dialysis (PD). It may be asymptomatic and detected accidentally. In most cases, no triggering factor is identi®ed w1x. We were recently confronted with a patient in whom hydrothorax has been secondary to rib fractures. Case. A 45-year-old male had been treated by PD for the past 9 years. He had been stable and active for all those years except for prolonged viral upper respiratory tract infections during winter months. Osteitis ®brosa was documented by radiography of distal claviculae. Twelve years ago, then a haemodialysis patient, he underwent a parathyroidectomy with reimplantation in the left arm of parathyroid tissue. His most recent plasma PTH level, 4 months before presentation, was 42 pguml. Due to an inadvertent fall he broke his left leg and two of his left ribs (ribs 8 and 9). The fractures of the ribs occasionally caused a cough but were treated conservatively. The leg fracture required open reduction, at which severe osteopenia was noticed. Four weeks after his discharge from the orthopaedic ward, the patient noticed a sudden decrease in volume of dialysate ef¯uent and increasing dyspnea. A large left pleural effusion was diagnosed by examination and chest X-ray. Thoracocentesis disclosed a transudate with a glucose concentration of 256 mg%, whereas the serum glucose concentration was 90 mg%. The diagnosis of a diaphragmatic leak of dialysate was further con®rmed by scintigraphy using macroaggregated Tc-99-labelled albumin, which was instilled into the peritoneal cavity (Figure 1). The patient was transferred to haemodialysis, using a cathe-ter inserted into the left internal jugular vein. The next day, an acute left haemothorax was diagnosed following a sudden drop in blood pressure and haemoglobin level from 9.1 to 8.0 mg%. Bleeding was attributed to a tear of a subcostal vessel in the vicinity of a rib fracture after computer tomo-graphy excluded the possibility of bleeding from a major blood vessel due to insertion of the central venous catheter. The bleeding into the pleural cavity was self-limited, but the patient eventually died from blood line sepsis. Comment. Hydrothorax is a well recognized complication of peritoneal dialysis occurring in 1.6% of patients; it is more common in females than in males, possibly promoted by previous stretching of the diaphragm during pregnancy. In 88% of cases the hydrothorax is right-sided and in 50% it develops within 30 days of initiation of PD w2x. It may …