The role of pediatric chest US in the diagnosis of hydrothorax complicating peritoneal dialysis

Posted By Laura Gabrieli
The role of pediatric chest US in the diagnosis of hydrothorax complicating peritoneal dialysis

ABSTRACT Hydrothorax is an uncommon but well-recognized complication of pediatric peritoneal dialysis (PD). Experience with pediatric patients on PD who develop hydrothorax is limited and diagnostic procedures are still debated. We describe the case of 2-year-old female, on automated peritoneal dialysis (APD) for end-stage renal disease (ESRD), who developed a right-sided hydrothorax, to discuss the diagnostic role of lung ultrasonography (US) in detecting pleural complications in children treated by PD. Lung US enables the detection of pleural complications like hydrothorax, in children with ESRD treated by PD. CASE REPORT A 2-year-old female with ESRD due to congenital nephrotic syndrome treated by APD presented to monthly peritoneal dialysis ambulatory visit with polypnea, dyspnea and reduced breath sounds and percussion dullness on the right side, with oxygen saturation of 88% on capillary hemogasanalysis. The patient started renal replacement therapy (RRT) with APD since six months with the following scheme therapy: a total volume exchange of 2000 mL, eight cycles, 240 mL for each charge, duration of treatment nine hours. Thereafter, the APD prescription was modified with mild increase of charge at 300 mL per cycle (less than 40 ml/kg), well toleraded by the patient. The recent clinical history showed fever two weeks before, treated with oral antibiotics for documented Streptococcical pharyngitis. In the days before the visit, she presented a mild increase of diuresis and reduced ultrafiltration. Test performance characteristics for the ability of lung US to diagnose pleural complications in this child were determined using chest X-rays as a reference standard. Lung US examinations were performed by the same experienced paediatric radiologist, using a 7.5 MHz linear and convex probe and both trans-thoracic and trans-abdominal approaches. The transthoracic US approach included examination in supin and both lateral decubitus positions of the anterior, lateral and posterior lung areas in caudo-cranial direction. The trans-abdominal US included the trans-hepatic and trans-splenic approach in supin position to examine both lung bases3. For the evaluation of pleural effusion, was used vector or convex transducer with a larger field of view to quantify the effusion. For the examination of the diaphragms, was used a tight convex transducer in the subxiphoid area to simultaneously view the right and the left hemidiaphragms excursion. A linear transducer is best for evaluation of each hemidiaphgram contour and muscle. Both chest X-rays and US showed a pleural effusion on the right side (FIG. 1-2) Clinical signs and syntoms, but also laboratory data were negative for other causes of hydrothorax, so a pleuro-peritoneal communication was suspected, PD was withheld, and the patient transitioned to temporary hemodialysis. After 5 weeks, the chest X-ray and the US did not identify any pleural effusion (FIG 3-4). The APD prescription w

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