Kidney Research and Clinical Practice 2018 Dec; 37(4): 423-423
Utility of indocyanine green for diagnosing peritoneal dialysis-related hydrothorax
Jun Young Lee , Jae-Won Yang, Seung Ok Choi, and Byoung-Geun Han
Department of Nephrology, Yonsei University Wonju College of Medicine, Wonju, Korea
Correspondence to: Jun Young Lee, Department of Nephrology, Yonsei University Wonju College of Medicine, 20 Ilsan-ro, Wonju 26426, Korea. E-mail: ORCID:
Received: August 20, 2018; Revised: September 3, 2018; Accepted: September 4, 2018; Published online: December 31, 2018.
© The Korean Society of Nephrology. All rights reserved.

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To the Editor:

Hydrothorax is a rare but important complication of peritoneal dialysis (PD). Although its pathogenesis remains unclear, hydrothorax is common in women and occurs predominantly on the right side [1]. We describe a patient with PD-related hydrothorax, which was confirmed using the indocyanine green (ICG) clearance test.

A 78-year-old woman with diabetes-related end-stage renal disease who began PD 33 months prior visited Department of Emergency with shortness of breath. Ultrasonography revealed massive right-sided pleural effusion, and pleural fluid analysis revealed a transudative characteristic. Cytological and microbiological examination of the pleural fluid showed no abnormalities. There was no evidence of heart failure or liver cirrhosis. ICG was mixed with peritoneal dialysate and instilled (2 L) into the peritoneal cavity. Subsequently, we observed drainage of green-colored pleural fluid. No specific adverse effects occurred during the ICG clearance test.

No single definitive test has been established for accurate diagnosis and localization of the defect in the pleuroperitoneum in such cases, and each method has its disadvantages. The pleural fluid-to-serum glucose ratio (“sweet” hydrothorax) shows high sensitivity and specificity for detecting pleuroperitoneal communication; however, a few patients demonstrate low pleural fluid-to-serum glucose ratios [2]. The povidone-iodine addition test can be performed only in patients using icodextrin for PD [3]. The methylene blue test is not valid and may cause chemical peritonitis [1]. Peritoneal scintigraphy is expensive and exposes patients to radiation [1]. Notably, a few patients have negative findings, as was observed in our patient. Video-assisted thoracoscopy is an invasive intraoperative procedure [4]. In conclusion, the ICG clearance test may be a reliable, simple, safe, and inexpensive method of differentiating between pleuroperitoneal communication and other causes of transudative hydrothorax in patients with PD.

  1. Tang, S, Chui, WH, and Tang, AW (2003). Video-assisted thoracoscopic talc pleurodesis is effective for maintenance of peritoneal dialysis in acute hydrothorax complicating peritoneal dialysis. Nephrol Dial Transplant. 18, 804-808.
    Pubmed CrossRef
  2. Momenin, N, Colletti, PM, and Kaptein, EM (2012). Low pleural fluid-to-serum glucose gradient indicates pleuroperitoneal communication in peritoneal dialysis patients: presentation of two cases and a review of the literature. Nephrol Dial Transplant. 27, 1212-1219.
    Pubmed CrossRef
  3. Camilleri, B, Glancey, G, Pledger, D, and Williams, P (2004). The icodextrin black line sign to confirm a pleural leak in a patient on peritoneal dialysis. Perit Dial Int. 24, 197.
  4. Lang, CL, Kao, TW, Lee, CM, Tsai, CW, and Wu, MS (2008). Video-assisted thoracoscopic surgery in continuous ambulatory peritoneal dialysis-related hydrothorax. Kidney Int. 74, 136.
    Pubmed CrossRef


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