Treatment of Hydrothorax Complicating Continuous Ambulatory Peritoneal Dialysis

Dr. Sona Funíaková, University Hospital, Department of Internal Medicine I, Kollárova 2, 036 59 Martin (Slovak Republic) Dear Sir, Peritoneal dialysis has become more widely known and used in Slovakia since 1991 and its use continues to grow. Some complications including hydrothorax may limit successful use of continuous ambulatory peritoneal dialysis (CAPD) [1]. Long-term management of this complication remains controversial, although surgeons experienced with surgical correction of hydrothorax in patients on CAPD recommend starting with conservative treatment. Following is a report of hydrothorax and its management in our patient, which reflects a conservative approach. The patient was a 45-year-old female with a history of urinary bladder surgery by age 1 ‚ EPH gestosis during her second pregnancy (1969), reflux nephropathy with secondary chronic pyelonephritis and surgery for vesicoureteral reflux (1983 – reimplanta-tion of the left ureter into the urinary bladder). From August 1992 to June 1993 she was treated for progressive uremia using hemodi-alysis twice weekly, 4 h/session. Due to severe renal anemia, erythropoietin was administered prior to each dialysis session. By April 1993, the function of the A-V fistula deteriorated and by May 9 it had become completely nonfunctional. On the recommendation of the patient’s gynecologist, nor-ethisterone was administered for 6 days prior to the complete closing of the A-V fistula. The patient’s thrombotic status (most probably in conjunction with erythropoietin treatment and the adverse estrogen effect of norethisterone) led to repeated thrombosis at the new A-V fistula. The patient was temporarily dialyzed using a subclavial catheter due to the unsatisfactory vessel status of the extremities. CAPD was started on June 2 immediately following surgical implantation of a Tenckhoff peritoneal catheter. The postoperative course and the exchanges of peritoneal dialysate were without complications. No serious changes of cardiopulmonary clinical status were found. At the end of June the patient was treated for a respiratory tract infection with a tenacious irritable cough. During an examination of July 22 the patient complained of occasional nausea and vomiting over a 3-week period, a prickling sensation in the right hip and noted a moderate worsening of breathing, and a need to cough especially in a supine position. She had gained approximately 3 kg, but did not feel bloated. Further examination showed an absence of alveolar breathing and a weakened percussion response of the right thorax up to the inferior margin of the right scapula. The chest X-ray showed right pleural effusion up to the fourth intercostal space (fig. 1). The pleural effusion obtained by pleural puncture was a