정진재, 이준영, 양재원, 한병근

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A Novel Technique to Diagnose Hydrothorax in Peritoneal Dialysis: Indocyanine Green

연세대학교 원주의과대학 내과학교실 (신장내과)

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정진재, 이준영, 양재원, 한병근

Massive hydrothorax is uncommon, but one of important complications of peritoneal dialysis. Several methods were used to diagnose hydrothorax in peri- toneal dialysis patients. Biochemical analysis of pleural fluid, methylene blue discoloration of pleural fluid, an addition of iodine to icodextrin dialysate, peritoneal scintigraphy, and visualization of pleura via video-assisted thoracoscopic surgery (VATS) are well known diagnostic techniques. However, there was no single definite method to diagnose hydrothorax with peritoneal dialysis patients. We describe a patient with CAPD related hydrothorax, who were confirmed by indocyanine green (ICG) mixing test. A 78-year-old female with ESRD on PD secondary to diabetic nephropathy visited the emergency room because of shortness of breath. She had been started CAPD for 33 months. On brief sonography demonstrated a massive right-sided pleural effusion and pleural fluid revealed transudate. Cytological and microbiological examination of pleural fluid showed no abnormalities. There was no evidence of heart failure and liver cirrhosis. ICG was mixed in peritoneal fluid and injected (2L) to peritoneum then green color pleural fluid was drained via the pleural fluid (Figure). There was no specific side effect during ICG mixing test. In the end, the patient made arteriovenous fistula and undergo hemodialysis. ICG is non-toxic, water soluble dye that is used for cardiac output measurement, hepatic function estimation, and retinal microcirculation assessment. Toxicity of ICG is low incidence and mild allergic reactions. In conclusion, we recommend that ICG mixing test may be a reliable, simple, non-harmful, and non-ex- pensive method in differentiating pleuroperitoneal communication from other causes of transudate hydrothorax in PD patients.

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Sirolimus induced lymphedema

울산대학교 서울아산병원 신장내과

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양은혜, 서유리, 백충희, 박수길

Sirolimus, inhibitor of the mammalian target of rapamycin (mTOR), is used as an immunosuppressant for organ transplantation and patients with auto- immune disorder. We would review a rare case of lymphedema, a rare complication of sirolimus. A 67-year-old female received living related kidney trans- plantation for end-stage of renal disease, unknown etiology. She got bilateral nephroureterectomy because ureteral malignancy could not be excluded. She had been on tacrolimus and azathioprine, and she changed from tacrolimus to sirolimus because of recurred bladder cancer because sirolimus has advantage of lower rate of malignancy compared to calcineurin inhibitors. 20 months after taking sirolimus (mean dose 1mg daily), She developed left lower limb edema. In outpatient clinic, sirolimus had been withdrawn due to edema. However, her leg edema and pain had gotten worsen. She was admitted to work up for progressive leg edema. She also had a history of bladder cancer and pulmonary thromboembolism. Therefore, we considered that leg edema might be induced by cancer invasion with lymph node enlargement or deep vein thrombosis. She had gotten abdomino-pelvic CT, lower extremity venography. CT findings are no evidence of tumor recurrence or deep vein thrombosis. We confirmed that there is no evidence of deep vein thrombosis on bilateral lower extremities. Lymphoscintigraphy demonstrated the visualization of left inguinal lymph node and failure of left iliac lymph node uptake on 1 and 2 hour de- layed image. Sirolimus induced lymphatic obstruction has been explained with various mechanisms that mTOR is downstream signal in the vascular epi- thelial growth factor pathway that mediates lymphatic survival, proliferation and migration, resulting in disrupting lymphangiogenesis. Her leg edema had not yet been improved. Sirolimus induced lymph edema can be partially relieved after discontinuation. Also Reversibility takes times few months to years after discontinuation of it. This case has importance that patients with lymphedema on sirolimus should be suspected due to complication caused by siroli- mus, which needs withdrawal to prevent irreversibility and disfiguration.