Acute hydrothorax in a peritoneal dialysis patient: long-term efficacy of autologous blood cell pleurodesis associated with small-volume peritoneal exchanges

Roberto Scarpioni

‘Guglielmo da Saliceto’ Piacenza Hospital Divisione di Nefrologia e Dialisi Piacenza Italy Email: rscarpioni{at}hotmail.com

Sir,

It was with interest that I read the manuscript by Tang et al. [1], on the treatment with thoracoscopic talc pleurodesis of acute hydrothorax in peritoneal dialysis (PD) patients. However, the ideal treatment of this complication, rare in PD, is not established.

I report our long-term successful experience with autologous blood cell pleurodesis associated with small-volume automated peritoneal exchanges (APD) in the treatment of acute right massive hydrothorax in one PD patient. A 58-year-old male patient with primary renal disease vasculitis, on continuous ambulatory peritoneal dialysis (CAPD) for 10 months because of repeated arterio-venous fistula thrombosis, with two peritonitis episodes during the first and the fourth months of CAPD, suddenly reported progressive shortness of breath. Clinical examination and chest X-rays permitted us to diagnose a massive right hydrothorax and an ultrasound-guided thoracentesis of 1350 ml successfully resolved the dyspnoea: bacteriological and cytological studies of the aspirate excluded cause of effusion.

After 8 weeks on haemodialysis (HD) via a right internal jugular vein catheter (CVC), subsequent resumption of CAPD, with four exchanges daily with 2 l bags, led to recurrence of massive right hydrothorax: the peritoneography with 50 ml i.p. of iopamidol in 1000 ml of dialysis fluid did not show the diaphragmatic site of leak.

An ultrasound-guided pleurocenthesis of 1200 ml was repeated: the pleural fluid resulted to be a transudate with a high glucose content of 360 mg/dl: the diagnosis of peritoneo-pleural leak was taken and, via a VenFlon2 (14 G), without either sedation or analgesia, we injected, once a time, 40 ml of autologous blood in the pleural cavity, without pain or other complications.

Right away the patient was invited to rotate in bed for 2–3 h to distribute the instilled blood in the pleural cavity.

After that HD was resumed but, because of CVC-related infection due to Pseudomonas aeruginosa, it was stopped 5 weeks later. The CVC was removed and CAPD was resumed with a right hydrothorax recurrence, suggesting a relapse of peritoneo-pleural leak.

After thoracentesis, another 50 ml of autologous blood instillation in the right pleural cavity was repeated, as described previously, with no side effects, and after 8 weeks of HD, APD was started with small-volume exchanges, in order to reduce the i.p. pressure to the lowest value [2]. Repeated chest Rx and pulmonary ultrasonography confirmed the complete pleural effusion re-adsorbtion over 14 months.

In the literature, several agents inducing an effective inflammatory reaction have been used for the treatment of hydrothorax complicating PD such as tetracycline, tissucol, talc and bleomycin [1,3,4].

Pleurodesis with autologous blood, rarely associated with fever or pain, is reported in patients with cancer or spontaneous pneumothorax [5,6], while its efficacy is controversial in the few PD patients followed over short time [710]. Our case shows that pleurodesis with autologous blood, associated with small-volume exchanges, after the temporary interruption of PD, represents a simple, safe, painless, eventually repeatable and effective in the long-term period, avoiding the discomfort and the costs of thoracoscopic manoeuvres.

Larger studies are necessary to confirm our experience.

Conflict of interest statement. None declared.

References

  1. Tang S, Chui WH, Tang AWC et al. Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis. Nephrol Dial Transplant 2003; 18: 804–808[Abstract/Free Full Text]
  2. Christidou F, Vayonas G. Recurrent acute hydrothorax in a peritoneal dialysis patient post successful management with small volumes of dialysate. Perit Dial Int 1995; 15: 389
  3. Kanaan N, Pieters T, Javiar F et al. Hydrothorax complicating continuous ambulatory peritoneal dialysis: successful management with talc pleurodesis under thoracoscopy. Nephrol Dial Transplant 1999; 14: 1590–1592[Abstract]
  4. Vlachoyannis J, Boettcher J, Brandt L, Schoeppe W. A new treatment for unilateral recurrent hydrothorax during continuous ambulatory peritoneal dialysis. Perit Dial Bull 1985; 5: 180–181[ISI]
  5. Dumire R, Crabbe MM, Mappin FG, Fontenelle LJ. Autologous blood pleurodesis for persistent pulmonary air leak. Chest 1992; 101: 64–66[Abstract]
  6. Blanco I, Canto Argiz H, Carro del Camino F, Fuentes Vigil J, Sala Blanco J. Pleurodesis with the patient’s own blood: the initial results in 14 cases. Arch Broncopneumol 1996; 32: 230–236
  7. Chao SH, Tsai TJ. Recurrent hydrothorax following repeated pleurodesis using autologous blood. Perit Dial Internat 1993; 13: 321–322[ISI]
  8. Catizone L, Zucchelli A, Zucchelli P. Hydrothorax in a peritoneal dialysis patient: successful treatment with intrapleural autologous blood instillation. Adv Perit Dial 1991; 7: 86–90[Medline]
  9. Suga T, Matsumoto Y, Nakajima K et al. Three cases of acute massive hydrothorax complicating continuous ambulatory peritoneal dialysis. Tokai J Exp Clin Med 1989; 14: 315–319[Medline]
  10. Hidai H, Takatsu S, Chiba T. Intrathoracic autologous blood in the treatment of massive hydrothorax following continuous ambulatory peritoneal dialysis. Perit Dial Bull 1989; 9: 221–223




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