Original article: general thoracic
Long-term follow-up of thoracoscopic pleurodesis for hydrothorax complicating peritoneal dialysis

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Abstract

Background. Massive hydrothorax is a significant complication of continuous ambulatory peritoneal dialysis (CAPD) and its ideal management remains undefined. Conservative management in the form of intermittent peritoneal dialysis had limited success. The use of conventional pleurodesis and open thoracotomy were associated with morbidities and limitations. We retrospectively reviewed the long-term outcome of 8 patients with massive hydrothorax complicating CAPD, 6 of whom received thoracoscopic pleurodesis.

Methods. Among 397 patients undergoing continuous ambulatory peritoneal dialysis during the period from 1994 to 1998, hydrothorax developed in 8 patients. Four patients were first treated with temporary intermittent peritoneal dialysis using 1-L exchange cycles. Three of them had a recurrence of the hydrothorax whereas only one could resume continuous ambulatory peritoneal dialysis successfully. Two patients then underwent conventional pleurodesis but failed. One of them was switched to hemodialysis. Thoracoscopic pleurodesis was performed for the remaining 2 patients together with 4 other patients with hydrothorax once this complication developed. There were no gross abnormalities including pleuroperitoneal communication sites identified. Talc poudrage was performed in 2 patients and mechanical rub pleurodesis in the other 4 patients. All had uncomplicated procedure and uneventful recovery.

Results. One patient after thoracoscopic pleurodesis was soon switched to hemodialysis for an unrelated reason. The other 5 patients resumed continuous ambulatory peritoneal dialysis with no recurrence of hydrothorax for a mean period of 50 months (range 19 to 84).

Conclusions. With thoracoscopic pleurodesis, patients resumed continuous ambulatory peritoneal dialysis without recurrence of hydrothorax on long-term follow-up.

Section snippets

Patients and methods

Among 397 patients undergoing CAPD during the period from 1994 to 1998 at our center, there were 8 patients in whom hydrothorax developed. Locally in Hong Kong, as a result of smaller body size of patients in general, three daily 2-L exchanges have been the standard starting therapy for CAPD in most centers. All 8 patients had massive right-sided hydrothorax with typical biochemical characteristics of crystal clear pleural fluid: low white blood cell count, low protein and lactate dehydrogenase

Previous treatment for the hydrothorax

Upon diagnosis of the hydrothorax, 4 patients (nos. 1 to 4) were first treated with intermittent peritoneal dialysis using 1-L exchange cycles for 4 to 6 weeks (Table 1). Apart from 1 patient (no. 2) who then resumed CAPD successfully for 64 months up to the last follow-up, 3 patients had recurrence of their hydrothorax at 6 to 8 weeks after CAPD was restarted. Two of them then received conventional pleurodesis with oxytetracycline (no. 4) or talc (no. 1) through a chest drain. They were both

Comment

Continuous ambulatory peritoneal dialysis is an increasingly utilized treatment modality for end-stage renal disease (ESRD) worldwide. Massive hydrothorax is an uncommon but well-recognized complication. It has been suggested that the development of this complication might require permanent discontinuation of peritoneal dialysis (patient no. 1 in this series) [3]. Locally, Hong Kong provides government reimbursement for ESRD treatment for most citizens and it is our policy to use CAPD as a

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Copyright © 2002 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.