From Peritoneum to Pleura: Unraveling an Uncommon Complication in a Patient on Peritoneal Dialysis

Introduction: Peritoneal dialysis (PD) may cause rare complications such as pleural effusion and hydrothorax from poor fluid migration into the pleural cavity due to intra-abdominal pressure. This may lead to respiratory distress or, rarely, lung collapse, impacting dialysis. In this case, transitioning from PD to hemodialysis (HD) resolved the patients hydrothorax, suggesting HD as an effective alternative for PD-related respiratory issues Case Description: A 74-year-old female with history of hypertension (HTN), hyperlipidemia (HLD), asthma, high blood pressure (STB in 190s) and ESRD 2/2 HTN versus FSGS, presented shortness of breath (SOB) for 2-3 days after missing a day of at-home PD. Check-up images show moderate right-sided pleural effusion, which acutely worsened after a PD retrial. A chest tube was placed, resulting in 2L of fluid being rapidly removed. Analysis of this fluid reveals consistencies with dialysate (transudative, very high glucose). There was high suspicion of hydrothorax from PD. A CT scan found no evidence of a diaphragm defect on CT Chest. No surgical intervention was recommended by CT surgery. The retrial of PD with her chest tube was conducted to determine pleural effusion reaccumulation before committing to HD, which showed fluid accumulation in the right pleural space. She could no longer remain on PD as it was complicated by right-sided hydrothorax. Patient proceeded with permacath placement and began HD. After beginning HD, the accumulation of fluid in her right pleural cavity ceased, and the chest tube was eventually removed. Her BP was better controlled and she experienced orthostatic hypotension (30+ mmHg decrease in systolics with standing, symptomatic). Discussion: This case highlights the importance of recognizing PD-associated hydrothorax as a potential complication in patients undergoing PD. Patients with hydrothorax can appear asymptomatic; a better indicator is analyzing the accumulated fluid for glucose concentration. Recurrence of fluid during a PD retrial, along with high-glucose transudative pleural effusion, unique to PD-related hydrothorax, confirmed the diagnosis. Transitioning to HD resolved the hydrothorax, improved blood pressure, and led to chest tube removal. Careful monitoring of PD patients with respiratory distress is key, and HD can be an alternative in recurrent hydrothorax.