Case report: the thoracoscopic surgery in peritoneal-pleural leakage. A valid therapeutic strategy


Pleuro-peritoneal leakage is an uncommon complication of peritoneal dialysis (PD). In this study, we report the case of a male patient (age 83), treated with PD (daytime single-exchange). In October 2019, hospitalization was necessary due to dyspnoea and a reduction of peritoneal ultrafiltration. A right pleural leakage resulted at chest x-ray. A regression of the pleural leakage was immediately observed after interrupting PD.

It was then performed a pleuro-peritoneal CT scan at baseline, followed by a second scan performed 4 hours after the injection of 2 L of isotonic solution with 100ml of contrast medium, which evidenced a pleuro-peritoneal communication. It was then decided to perform a video-assisted thoracoscopic surgery (VATS), that showed no evidence of diaphragm communication. It was then executed a pleurodesis using sterile talcum. The patient was released on the 3rd day, with a conservative therapy and a low-protein diet. After 2 weeks a new pleuro-peritoneal CT scan with contrast medium was executed. This time the scan evidenced the absence of contrast medium in the thoracic cavity. The patient then resumed PD therapy, with 3 daily exchanges with isotonic solution (volume 1.5 L), showing no complications.

Concerning the treatment of pleuro-peritoneal leakage, VATS allows both the patch-repairing of diaphragmatic flaws and the instillation of chemical agents. In our case, VATS allowed the chemical pleurodesis which in turn enabled, in just 2 weeks of conservative treatment, the resuming of PD. In conclusion, this methodology is a valid option in the treatment of pleuro-peritoneal leakage in PD patients.


Keywords: pleuro-peritoneal leakage, video-assisted thoracoscopic surgery, peritoneal dialysis, end stage renal disease


Pleuro-peritoneal leakage is an uncommon complication of peritoneal dialysis (PD) with an incidence of 1.6%, first described in 1967 [1]. It occurs in higher frequency in female patients and in the right hemithorax (90% of cases) [2]. Frequently accompanied by dyspnea, it is asymptomatic in 25% of cases [3].

The diagnosis is established observing pleural leakage and performing chest x-ray, albumin-marked scintigraphy and CT scan of peritoneal area [4].

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Atrial fibrillation in severe and end stage renal disease: from oral anticoagulation therapy to percutaneous left atrial appendage occlusion


Non-valvular atrial fibrillation (AF) is the most frequent arrhythmia in the general population and its prevalence increases with age. The prevalence and incidence of AF is high in patients with chronic kidney failure (CKD). The most important complication associated with AF, both in the general population and in that with CKD, is thromboembolic stroke. For this reason, in patients with AF, the Guidelines indicate oral anticoagulant therapy (OAT) with vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs) for thromboembolic risk prevention. Patients with severe CKD and, in particular, with end stage renal disease (ESRD) undergoing renal replacement therapy, often have both a high thromboembolic and hemorrhagic risk and therefore present both an indication and a contraindication to OAT. In addition, patients with severe or ESRD were excluded from trials that showed the efficacy of different antithrombotic drugs in patients with AF. Thus there is no evidence of the effectiveness of OAT in this population. This review deals with the issues related to OAT in patients with severe or end stage CKD and the possible use of percutaneous closure of the left auricula (LAAO), recently proposed as an alternative in patients with an absolute contraindication of OAT in this population.

Key words

Atrial fibrillation; oral anticoagulant therapy; bleeding; severe chronic kidney disease; end stage renal disease; left atrial appendage occlusion.

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Lista delle abbreviazioni

AF Atrial Fibrillation

C-G Cockroft-Gault

CKD Chronic Kidney Disease 

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