Chylothorax and Chylopericardium in a Patient on Dialysis

Introduction: Chylous effusions, a rare complication in hemodialysis patients, was observed in a patient with central venous stenosis (CVS) following arteriovenous fistula (AVF) creation. Case Description: A 24-year-old man with acute kidney injury on CKD stage IV underwent hemodialysis via right intrajugular venous catheter. After creating a left arm AVF, he developed dyspnea and left arm swelling. CT chest showed bilateral pleural and pericardial effusions with milky fluid extracted from a right chest tube and pericardial drain with triglycerides levels of 1,008 mg/dL and 1,349 mg/dL respectively, indicating Chylothorax and Chylopericardium (Fig 1). Dynamic MR lymphangiography and 3-D MR angiography revealed bifid thoracic duct with dilation and lymphatic leakage around the diaphragmatic hiatus and right lower thorax (Fig 2A). Stenosis was noted in the right brachiocephalic vein and superior vena cava (SVC) with occlusion in the left brachiocephalic and left subclavian veins (Fig 2B). He recovered to CKD stage IV after 6 months of dialysis. He underwent AVF ligation, dialysis catheter removal, and venoplasty of SVC, left subclavian, brachiocephalic veins, followed by kissing stents through SVC and brachiocephalic veins (Fig 2C). Despite these interventions, stenosis reccurred. Consequently, ligation of the right thoracic duct and embolization of the left one resolved the effusions. Discussion: CVS involves narrowing of central veins, commonly seen in dialysis patients. AVF creation can exacerbate symptoms by raising venous pressure. Rarely, CVS leads to Chylous effusions due to increased pressure in the thoracic duct causing leakage. In our patient, chylous effusions resulted from aggravated CVS, worsened by the dialysis catheter and elevated venous pressure after AVF creation.