Chylous Ascites in a Patient on Peritoneal Dialysis with Recurrent T Cell Post-transplant Lymphoproliferative Disorder after Transplantation from a Living Unrelated Kidney Donor

Introduction: Chylous ascites is a rare manifestation of abdominal lymphatic system disruption; ascites fluid appears cloudy and is characterized by elevated triglyceride levels. Few reports exist of chylous ascites in patients on peritoneal dialysis (PD) or in patients following solid organ transplantation. We report a case of chylous ascites in a patient on peritoneal dialysis with recurrent post-transplant lymphoproliferative disorder (PTLD) following a living unrelated kidney transplant (LUKT). Case Description: A 54 year old man with ESKD due to IgA nephropathy who received a LUKT in 2018 that was complicated by T-cell mediated rejection in 2022 leading to allograft failure and initiation of peritoneal dialysis (PD) in 2023 presented with cloudy PD fluid and mild abdominal discomfort. Additional history included T-Cell lymphoma characterized as PTLD in 2021 treated to complete metabolic response. Both donor and recipient were EBV seropositive at the time of LUKT. Gross examination revealed cloudy PD fluid; initial PD fluid studies demonstrated 84 total nucleated cells per microliter with 1% neutrophils. PD fluid cultures and smears for acid-fast bacilli were both negative. Ascites fluid triglyceride level was 412 mg/dL (serum 133 mg/dL). A CT abdomen and pelvis demonstrated bulky lymphadenopathy and a PET-CT scan confirmed severe progression of lymphoma. A PD catheter was appropriately positioned. PD was limited by inability to tolerate therapeutic fill volumes and persistent chylous ascites. Hemodialysis was initiated. Following initiation of chemotherapy, the patient developed tumor lysis syndrome and eventually expired. Discussion: We report chylous ascites as the initial presentation of severe recurrent PTLD following LUKT. Cloudy PD fluid warrants immediate and thorough evaluation and may raise suspicion for PTLD in post-transplant patients. Large volumes of chylous ascites may impair continuation of PD.