Nephrol Dial Transplant (2003) 18: 2201
© 2003 European Renal Association-European Dialysis and Transplant Association
Letter and Reply
Reply
Department of Medicine University of Hong Kong Queen Mary Hospital Hong Kong People’s Republic of China Email: scwtang{at}hkucc.hku.hk
Sir,
Scarpioni described a patient with acute hydrothorax complicating CAPD who was treated with repeated autologous blood instillation into the pleural cavity together with a switch in the mode of dialysis to HD followed by prolonged low-volume APD. Although a pleuroperitoneal communication was clearly present in this patient, peritoneography failed to demonstrate the leakage, confirming our experience that peritoneography is an insensitive tool of investigation in this clinical scenario [1]. Although autologous blood appeared to be successful in this patient, he required three intervening periods of HD spanning 21 weeks, followed by another 14 months of low-volume APD before CAPD could be resumed. The socioeconomic impact of such a protracted course of alternative dialytic therapy can be substantial, particularly in places where access to HD facilities is scarce such as Hong Kong [2]. On the other hand, the mean duration of HD was only 6 weeks in our cohort of patients treated with VATS talc pleurodesis [1]. Furthermore, one must be cautious that autologous blood is an unreliable sclerosing agent such that pleural adhesion was not always firmly fixed, which may result in frequent recurrence [3,4]. Partial adhesions render subsequent thoracoscopic manipulation more difficult, if not impossible, because of increased bleeding risk and prolonged operation time. Indeed, in animal models, autologous blood exhibited no significant pleurodesis [5], and carries an increased risk of intrathoracic infection in human subjects with spontaneous pneumothoraces [6]. Other drawbacks of autologous blood are the lack of consensus on various technical aspects, such as the optimum amount of blood to be instilled, the number of instillations to perform and, if multiple instillations are required, what the interval between them should be. Further study is needed to determine the place of this technique in the clinical management of PD-related acute hydrothorax.
Conflict of interest statement. None declared.
References
- Tang S, Chui WH, Tang AW et al. Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis. Nephrol Dial Transplant 2003; 18: 804–808
[Abstract/Free Full Text] - Lai KN, Lo WK. Optimal peritoneal dialysis for patients from Hong Kong. Perit Dial Int 1999; 19 [Suppl]: S26–S31
- Suga T, Matsumoto Y, Nakajima K et al. Three cases of acute massive hydrothorax complicating continuous ambulatory peritoneal dialysis (CAPD). Tokai J Exp Clin Med 1989; 14: 315–319[Medline]
- Chao SH, Tsai TJ. Recurrent hydrothorax following repeated pleurodesis using autologous blood. Perit Dial Int 1993; 13: 321–322[Medline]
- Mitchem RE, Herndon BL, Fiorella RM, Molteni A, Battie CN, Reisz GR. Pleurodesis by autologous blood, doxycycline, and talc in a rabbit model. Ann Thorac Surg 1999; 67: 917–921
[Abstract/Free Full Text] - Cagirici U, Sahin B, Cakan A, Kayabas H, Buduneli T. Autologous blood patch pleurodesis in spontaneous pneumothorax with persistent air leak. Scand Cardiovasc J 1998; 32: 75–78[Medline]
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