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“Sweet” hydrothorax (SH) is a complication in patients with peritoneal dialysis. Increase in intra-abdominal pressure because of flow of peritoneal fluid and its permanence can produce fluid effusion through the pleuroperitoneal communication, leading to hydrothorax. The incidence reported in the literature varies between 1.6% and 6% occurring at any time during peritoneal dialysis follow-up, with more frequent involvement of right hemithorax. We report the case of a patient with SH confirmed with the biochemical analysis of the pleural fluid given the clinical and radiological suspicion, deciding the definitive switch to hemodialysis.
A 74-year-old male patient with chronic kidney disease has been on automated peritoneal dialysis (ADP) for 8 months. During his therapy; he presented recurrent peritonitis that required a catheter change 6 months after the start of ADP. He was admitted to the emergency department due to dyspnea, non-specific chest pain, uncontrolled blood pressure, and desaturation requiring supplemental oxygen. The chest x-ray showed signs of pleural effusion in the lower third of the right hemithorax. Thoracentesis was performed obtaining 1500 cc of clear pleural fluid, compatible with transudate which was attributed to acute pulmonary edema in the context of hypertensive crisis, and after resolution of symptoms, medical discharge was given with appropriate adjustments to optimize ultrafiltration. After 8 days he was admitted to the emergency room again due to the appearance of dyspnea documenting right pleural effusion.
Drainage of 2000 cc of pleural fluid was performed, there was no clarity of the rapid recurrence regarding the pleural effusion, so it was decided to calculate pleural/serum glucose gradient with a report of 50 mg/dl diagnosing SH. Upon diagnosis, insertion of a permanent hemodialysis catheter was indicated, and the peritoneal catheter was removed. After the described intervention, the patient had satisfactory evolution without new episodes of pleural effusion.
SH is a rare complication in peritoneal dialysis, but it is essential to have it in the panorama of differential diagnoses when the patient debuts with any of the symptoms described, given that this entity impacts the patient's quality of life, the effectiveness of the therapy and requires targeted treatment with a high risk of transient or definitive switch to hemodialysis. As options for treatment are stopping peritoneal dialysis therapy for 2 to 3 weeks with low volume strategy effective in 54% of the cases, pleurodesis by thoracotomy or thoracoscopy with high effectiveness above 90% and 10% of recurrency. All measures to prevent episodes of peritonitis are significant as a conditioning event for the development of this unusual complication.