Triple Serosal Involvement in End-Stage Renal Disease (ESRD): A Case of Atypical Uremic Polyserositis With Elevated Serum-Ascites Albumin Gradient and Alkaline Phosphatase

Uremic polyserositis is a rare and often underdiagnosed manifestation of end-stage renal disease (ESRD), typically characterized by concurrent or sequential inflammation of multiple serosal membranes. We report a diagnostically challenging case of a 40-year-old woman with ESRD on intermittent hemodialysis who presented with dyspnea following a missed dialysis session. Imaging revealed bilateral pleural effusions, a moderate-to-large pericardial effusion, and ascites. Fluid analyses from thoracentesis and pericardiocentesis showed sterile, hemorrhagic, and exudative effusions. Ascitic fluid demonstrated a serum-ascites albumin gradient (SAAG) of 2.8, an unusual finding, as uremic ascites typically presents with a SAAG of <1.1. Despite the elevated SAAG, liver imaging and function were unremarkable, and no signs of portal hypertension were observed. The patient improved clinically with dialysis and pericardial drainage but later decompensated after another missed session, with recurrence of effusions and similar biochemical features, which again resolved with renal replacement therapy. This case highlights several atypical features of uremic polyserositis, including high SAAG ascites, markedly elevated alkaline phosphatase, and gamma-glutamyl transferase, in the absence of structural liver disease. These findings underscore how systemic inflammation and altered peritoneal dynamics in ESRD can produce biochemical patterns that mimic hepatic pathology. The strong temporal correlation between missed dialysis and symptom recurrence further supported a uremic etiology. Given the sterile nature of the effusions, lack of evidence for autoimmune or malignant processes, and consistent response to dialysis, uremic polyserositis was deemed the most plausible diagnosis. In a clinical landscape where this entity is increasingly rare, our case emphasizes the importance of considering uremic polyserositis in patients with ESRD and recurrent, unexplained serosal effusions, especially when classical fluid parameters do not conform to expected patterns. Awareness of such atypical presentations is essential to avoid unnecessary interventions and to guide appropriate, dialysis-focused management.