Chylous ascites

A 43-year-old man presented with a 2-week history of foamy urine, progressive oedema of his lower limbs, ascites and a 28-lb weight gain. He denied any trauma or surgery in the past. On physical examination, profound pitting oedema (4+) in the extremities and tautness of the abdominal wall with flattening of the umbilicus and positive shifting dullness was noted. Sono-guided paracentesis for symptom relief disclosed a milky appearance of the ascites with a total amount of 2000 mL (Figure 1). Laboratory evaluation showed serum albumin 1.2 g/dL, ascites albumin 0.7 g/dl, serum total cholesterol 653 mg/dL, ascites cholesterol 25 mg/dL, serum triglyceride 255 mg/dL, ascites triglyceride 8653 mg/dL, 24-h urine protein 27.3 g/day and negative culture and cytology of the ascites analysis. His diagnosis was minimal change disease with nephrotic syndrome based on sono-guided kidney biopsy. Prednisolone (1 mg/kg/day) was administered accordingly, and the patient reported an excellent clinical course without rebound proteinuria or chylous ascites. Chylous ascites, defined by a triglyceride concentration of >110 mg/dL (1.24 mmol/L) in the peritoneal fluid [1], is a peritoneal fluid with milky appearance rich in triglycerides with an estimated incidence of 1 per 20 000 admissions [2]. A variety of causes have been well defined, including liver cirrhosis, malignancies, infectious diseases, traumatic causes, postoperative conditions, congenital diseases, inflammatory processes and miscellaneous causes [3]. Chylous ascites was documented in 52% of patients with nephrotic syndrome based on detection of opalescent effusions [4] rather than by checking the triglyceride level of the peritoneal fluid. The pathogenesis of chylous ascites in nephrotic syndrome is still a mystery, but hypoalbuminaemia-associated bowel oedema with resultant lacteal leakage or malabsorption has been offered as a speculative explanation [4]. The key treatment is to achieve complete remission of the nephrotic syndrome.