Hybrid Dialysis in Volume Management of a Patient with Chylous Ascites on Hemodialysis

Introduction: Chylous ascites is a rare condition characterized by a milky appearance of peritoneal fluid and elevated triglyceride levels, typically caused by lymphatic obstruction or leakage. Its occurrence in end-stage renal disease (ESRD) patients on chronic hemodialysis is uncommon. The coexistence of cirrhotic ascites, malnutrition, and intradialytic hypotension (IDH) complicates fluid management, making it difficult to achieve adequate fluid removal and dialysis delivery. Case Description: A 36-year-old woman with ESRD from type 1 diabetes had received maintenance hemodialysis via an arteriovenous fistula (AVF) twice weekly for 10 years. She experienced dyspnea, and echocardiography revealed severe pulmonary hypertension, likely due to primary tricuspid regurgitation and AVF. She underwent tricuspid valve repair. Within a year, she developed refractory ascites from cardiac cirrhosis, requiring intermittent paracentesis. She became anuric and required hemodialysis 3 times weekly with ultrafiltration of 2-3 L/session and paracentesis twice weekly. Eventually, she developed frequent IDH, leading to insufficient fluid removal and worsening volume overload. Her ascitic fluid became chylous, with triglycerides of 332 mg/dL. Imaging showed no lymphatic obstruction or malignancy. She was diagnosed with chylous ascites due to cardiac cirrhosis from heart failure. As cardiac disease precluded transplant, she received long-term medium-chain triglyceride supplementation and hybrid dialysis (hemodialysis plus peritoneal dialysis), allowing daily ascitic fluid drainage and better volume control. Discussion: Patients with advanced renal, liver, and heart disease may develop chylous ascites, posing complex fluid challenges. Hybrid dialysis offers better hemodynamic stability and simultaneous ascites drainage, supporting volume and solute control.