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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44;</span></p><p class="elsevierStylePara">Peritoneal dialysis &#40;PD&#41; is an increasingly frequent therapeutic option for advanced chronic kidney disease&#46; However&#44; this technique is not exempt from complications&#44; the most common being peritonitis&#46; Although you may also observe infections in the exit site of the peritoneal catheter&#44; infection of the subcutaneous tunnel&#44; hernias&#44; abdominal or lumbar pain&#44; haemoperitoneum&#44; chylothorax&#44; pleuroperitoneal communication or hydrothorax&#44; among others&#46;</p><p class="elsevierStylePara">The infusion of fluid in the peritoneal cavity increases intraabdominal pressure&#44; which may cause the peritoneal fluid to flow into the chest&#44; leading to pleuroperitoneal communication&#46; Cases of pleuroperitoneal communication secondary to peritonitis have also been described&#46;<span class="elsevierStyleSup">1&#46;2&#46;</span></p><p class="elsevierStylePara">We present the case of a 77-year-old male with chronic kidney disease&#44; probably secondary to nephroangiosclerosis&#44; who was on continuous ambulatory PD for 15 days&#46; On the 8th day&#44; the patient had an episode of peritonitis&#44; caused by<span class="elsevierStyleItalic"> Streptococcus</span> &#40;<span class="elsevierStyleItalic">viridans</span><span class="elsevierStyleItalic">group</span>&#41; and was treated according to protocol with ciprofloxacin and vancomycin&#46; The patient went to the emergency department reporting dyspnoea&#44; fever and coughing for 24 hours&#44; along with a deficit of ultrafiltration in recent days&#46;</p><p class="elsevierStylePara">The examination showed revealed a general poor health status accompanied by tachypnoea and bilateral hypoventilation&#44; more pronounced in the right pulmonary area&#46;</p><p class="elsevierStylePara">A chest x-ray showed a moderate right pleural effusion&#44; which was mild on the left side&#46;</p><p class="elsevierStylePara">Treatment was started with empirical antibiotics for respiratory infection&#44; reducing the febrile syndrome while the dyspnoea continued&#46;</p><p class="elsevierStylePara">Therapeutic and diagnostic thoracentesis was performed&#44; with transudate characteristics&#46; We found greater glucose in pleural fluid than in plasma&#46; Dyspnoea improved and peritoneal fluid was cultured&#44; showing negative results&#46;</p><p class="elsevierStylePara">Given the suspicion of pleuroperitoneal communication&#44; an isotopic peritoneogram with 99mTc-MAA was performed&#46; The presence of the radiotracer activity at the right hemithorax suggested the existence of pleuroperitoneal communication in this hemithorax &#40;Figure&#41;&#46;</p><p class="elsevierStylePara">Having confirmed the diagnosis of pleuroperitoneal communication&#44; it was decided to temporarily suspend PD and the patient was transferred to haemodialysis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Patients on PD may present technique-related complications&#44; the most frequent being peritonitis&#44; catheter-related infections&#44; hernias&#59; and among the less frequent ones is pleuroperitoneal communication&#46;<span class="elsevierStyleSup">2&#46;3</span> This occurs by congenital or acquired diaphragmatic defects&#44; due to an increase in intra-abdominal pressure when instilling peritoneal fluid&#46; This can also be associated&#44; in some cases&#44; with peritonitis episodes&#46;<span class="elsevierStyleSup">1</span> Its incidence rate ranges between 1&#46;6&#37; and 2&#37;&#44; although it is believed to be greater in some cohorts&#46; It is more frequent in women and on the right-hand side&#46; Our patient is a male who presented right pleuroperitoneal communication&#44; and whose diagnosis was reached due to the clinical suspicion in the presence of dyspnoea&#44; hypoventilation&#44; and decreased ultrafiltration&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Chest x-ray revealed pleural effusion&#46; The thoracentesis showed a liquid with characteristics of fluid transudate&#44; and the concentration of glucose in pleural fluid was greater than in plasma&#46;<span class="elsevierStyleSup">2&#46;3</span></p><p class="elsevierStylePara">The isotopic peritoneogram with 99mTc-MAA&#44; showing pleuroperitoneal communication&#44; was very useful for confirming the diagnosis&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">Before diagnosis other causes of dyspnoea should be ruled out&#44; such as salt retention&#44; heart failure&#44; hypoproteinaemia&#44; infections or neoplasias&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Treatment consists of the final or temporary cessation of PD&#44; with peritoneal rest and transition to haemodialysis&#46; In some cases where the patient maintains residual diuresis&#44; you may continue automated PD &#40;APD&#41; at low volumes or APD at low volumes with dry day&#46; In some occasions&#44; it is necessary to perform pleurodesis&#44; either chemical &#40;tetracycline&#41;&#44; surgical or with the patient&#39;s blood&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">In our case&#44; the decision was peritoneal rest with temporary transition to haemodialysis&#46;</p><p class="elsevierStylePara">In some cases&#44; treatment does not deliver good results&#44; giving rise to the abandonment of the technique &#40;PD&#41; and the final transition to haemodialysis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11489&#95;16025&#95;33488&#95;en&#95;f1&#95;1311489&#46;jpg" class="elsevierStyleCrossRefs"><img src="11489_16025_33488_en_f1_1311489.jpg" alt="Peritoneal scintigraphy with 99mTc-MAA "></img></a></p><p class="elsevierStylePara">Figure 1&#46; 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Pleuroperitoneal communication in peritoneal dialysis patient
Comunicación pleuroperitoneal en paciente en diálisis peritoneal
Beatriz García-Maldonadoa, Manuel Guerrero-Ortizb, J. Ramón Gómez-Fuentesb, Remedios Garófano-Lópeza, M. Carmen Prados-Solera, M. Dolores Del Pino y Pinoa
a Servicio de Nefrología, Complejo Hospitalario Torrecárdenas, Almería,
b Servicio de Medicina Nuclear, Complejo Hospitalario Torrecárdenas, Almería,
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    "textoCompleto" => "<p class="elsevierStylePara"><span class="elsevierStyleBold">To the Editor&#44;</span></p><p class="elsevierStylePara">Peritoneal dialysis &#40;PD&#41; is an increasingly frequent therapeutic option for advanced chronic kidney disease&#46; However&#44; this technique is not exempt from complications&#44; the most common being peritonitis&#46; Although you may also observe infections in the exit site of the peritoneal catheter&#44; infection of the subcutaneous tunnel&#44; hernias&#44; abdominal or lumbar pain&#44; haemoperitoneum&#44; chylothorax&#44; pleuroperitoneal communication or hydrothorax&#44; among others&#46;</p><p class="elsevierStylePara">The infusion of fluid in the peritoneal cavity increases intraabdominal pressure&#44; which may cause the peritoneal fluid to flow into the chest&#44; leading to pleuroperitoneal communication&#46; Cases of pleuroperitoneal communication secondary to peritonitis have also been described&#46;<span class="elsevierStyleSup">1&#46;2&#46;</span></p><p class="elsevierStylePara">We present the case of a 77-year-old male with chronic kidney disease&#44; probably secondary to nephroangiosclerosis&#44; who was on continuous ambulatory PD for 15 days&#46; On the 8th day&#44; the patient had an episode of peritonitis&#44; caused by<span class="elsevierStyleItalic"> Streptococcus</span> &#40;<span class="elsevierStyleItalic">viridans</span><span class="elsevierStyleItalic">group</span>&#41; and was treated according to protocol with ciprofloxacin and vancomycin&#46; The patient went to the emergency department reporting dyspnoea&#44; fever and coughing for 24 hours&#44; along with a deficit of ultrafiltration in recent days&#46;</p><p class="elsevierStylePara">The examination showed revealed a general poor health status accompanied by tachypnoea and bilateral hypoventilation&#44; more pronounced in the right pulmonary area&#46;</p><p class="elsevierStylePara">A chest x-ray showed a moderate right pleural effusion&#44; which was mild on the left side&#46;</p><p class="elsevierStylePara">Treatment was started with empirical antibiotics for respiratory infection&#44; reducing the febrile syndrome while the dyspnoea continued&#46;</p><p class="elsevierStylePara">Therapeutic and diagnostic thoracentesis was performed&#44; with transudate characteristics&#46; We found greater glucose in pleural fluid than in plasma&#46; Dyspnoea improved and peritoneal fluid was cultured&#44; showing negative results&#46;</p><p class="elsevierStylePara">Given the suspicion of pleuroperitoneal communication&#44; an isotopic peritoneogram with 99mTc-MAA was performed&#46; The presence of the radiotracer activity at the right hemithorax suggested the existence of pleuroperitoneal communication in this hemithorax &#40;Figure&#41;&#46;</p><p class="elsevierStylePara">Having confirmed the diagnosis of pleuroperitoneal communication&#44; it was decided to temporarily suspend PD and the patient was transferred to haemodialysis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">DISCUSSION</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">Patients on PD may present technique-related complications&#44; the most frequent being peritonitis&#44; catheter-related infections&#44; hernias&#59; and among the less frequent ones is pleuroperitoneal communication&#46;<span class="elsevierStyleSup">2&#46;3</span> This occurs by congenital or acquired diaphragmatic defects&#44; due to an increase in intra-abdominal pressure when instilling peritoneal fluid&#46; This can also be associated&#44; in some cases&#44; with peritonitis episodes&#46;<span class="elsevierStyleSup">1</span> Its incidence rate ranges between 1&#46;6&#37; and 2&#37;&#44; although it is believed to be greater in some cohorts&#46; It is more frequent in women and on the right-hand side&#46; Our patient is a male who presented right pleuroperitoneal communication&#44; and whose diagnosis was reached due to the clinical suspicion in the presence of dyspnoea&#44; hypoventilation&#44; and decreased ultrafiltration&#46;<span class="elsevierStyleSup">2</span></p><p class="elsevierStylePara">Chest x-ray revealed pleural effusion&#46; The thoracentesis showed a liquid with characteristics of fluid transudate&#44; and the concentration of glucose in pleural fluid was greater than in plasma&#46;<span class="elsevierStyleSup">2&#46;3</span></p><p class="elsevierStylePara">The isotopic peritoneogram with 99mTc-MAA&#44; showing pleuroperitoneal communication&#44; was very useful for confirming the diagnosis&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">Before diagnosis other causes of dyspnoea should be ruled out&#44; such as salt retention&#44; heart failure&#44; hypoproteinaemia&#44; infections or neoplasias&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Treatment consists of the final or temporary cessation of PD&#44; with peritoneal rest and transition to haemodialysis&#46; In some cases where the patient maintains residual diuresis&#44; you may continue automated PD &#40;APD&#41; at low volumes or APD at low volumes with dry day&#46; In some occasions&#44; it is necessary to perform pleurodesis&#44; either chemical &#40;tetracycline&#41;&#44; surgical or with the patient&#39;s blood&#46;<span class="elsevierStyleSup">5</span></p><p class="elsevierStylePara">In our case&#44; the decision was peritoneal rest with temporary transition to haemodialysis&#46;</p><p class="elsevierStylePara">In some cases&#44; treatment does not deliver good results&#44; giving rise to the abandonment of the technique &#40;PD&#41; and the final transition to haemodialysis&#46;</p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">&#160;</p><p class="elsevierStylePara">The authors affirm that they have no conflicts of interest related to the contents of this article&#46;</p><p class="elsevierStylePara"><a href="grande&#47;11489&#95;16025&#95;33488&#95;en&#95;f1&#95;1311489&#46;jpg" class="elsevierStyleCrossRefs"><img src="11489_16025_33488_en_f1_1311489.jpg" alt="Peritoneal scintigraphy with 99mTc-MAA "></img></a></p><p class="elsevierStylePara">Figure 1&#46; Peritoneal scintigraphy with 99mTc-MAA </p>"
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Article information
ISSN: 20132514
Original language: English
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