NDT Plus (2010) 3: 315 doi: 10.1093/ndtplus/sfq004 Advance Access publication 28 February 2010
Images in Nephrology (Section Editor: G. H. Neild)
Chylous ascites Zi-Hong You2, An-Hang Yang1,3, Wu-Chang Yang1,2, Tung-Po Huang1,2 and Chih-Ching Lin1,2 1
School of Medicine, National Yang-Ming University, Taipei, Taiwan, 2Division of Nephrology, Department of Medicine and Department of Pathology, Taipei Veterans General Hospital, Taipei, Taiwan
3
Correspondence and offprint requests to: Chih-Ching Lin; E-mail: [email protected]
A 43-year-old man presented with a 2-week history of foamy urine, progressive oedema of his lower limbs, ascites and a 28-lb weight gain. He denied any trauma or surgery in the past. On physical examination, profound pitting oedema (4+) in the extremities and tautness of the abdominal wall with flattening of the umbilicus and positive shifting dullness was noted. Sono-guided paracentesis for symptom relief disclosed a milky appearance of the ascites with a total amount of 2000 mL (Figure 1). Laboratory evaluation showed serum albumin 1.2 g/dL, ascites albumin 0.7 g/dl, serum total cholesterol 653 mg/dL, ascites
cholesterol 25 mg/dL, serum triglyceride 255 mg/dL, ascites triglyceride 8653 mg/dL, 24-h urine protein 27.3 g/day and negative culture and cytology of the ascites analysis. His diagnosis was minimal change disease with nephrotic syndrome based on sono-guided kidney biopsy. Prednisolone (1 mg/kg/day) was administered accordingly, and the patient reported an excellent clinical course without rebound proteinuria or chylous ascites. Chylous ascites, defined by a triglyceride concentration of >110 mg/dL (1.24 mmol/L) in the peritoneal fluid [1], is a peritoneal fluid with milky appearance rich in triglycerides with an estimated incidence of 1 per 20 000 admissions [2]. A variety of causes have been well defined, including liver cirrhosis, malignancies, infectious diseases, traumatic causes, postoperative conditions, congenital diseases, inflammatory processes and miscellaneous causes [3]. Chylous ascites was documented in 52% of patients with nephrotic syndrome based on detection of opalescent effusions [4] rather than by checking the triglyceride level of the peritoneal fluid. The pathogenesis of chylous ascites in nephrotic syndrome is still a mystery, but hypoalbuminaemia-associated bowel oedema with resultant lacteal leakage or malabsorption has been offered as a speculative explanation [4]. The key treatment is to achieve complete remission of the nephrotic syndrome. Conflict of interest statement. None declared.
References 1. Kjeldsberg C, Knight J. Body Fluid: Laboratory Examination of Cerebrospinal, Seminal, Serous and Synovial Fluid. Chicago, IL: ASCP Press, 19933rd edition 2. Press PW, Press NO, Kaufman SD. Evaluation and management of chylous ascites. Ann Intern Med 1982; 96: 358–365 3. Cardenas A, Chopra S. Chylous ascites. Am J Gastroenterol 2002; 97: 1896–1900 4. Lindenbaum J, Scheidt SS. Chylous ascites and the nephrotic syndrome. Report of a case associated with renal vein thrombosis. Am J Med 1968; 44: 830–836 Fig. 1. Peritoneal fluid with milky appearance drained from the patient with an amount around 2000 mL.
Received for publication: 1.1.10; Accepted in revised form: 18.1.10
© The Author 2010. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For permissions, please e-mail: [email protected]
Images in Nephrology (Section Editor: G. H. Neild)
Chylous ascites Zi-Hong You2, An-Hang Yang1,3, Wu-Chang Yang1,2, Tung-Po Huang1,2 and Chih-Ching Lin1,2 1
School of Medicine, National Yang-Ming University, Taipei, Taiwan, 2Division of Nephrology, Department of Medicine and Department of Pathology, Taipei Veterans General Hospital, Taipei, Taiwan
3
Correspondence and offprint requests to: Chih-Ching Lin; E-mail: [email protected]
A 43-year-old man presented with a 2-week history of foamy urine, progressive oedema of his lower limbs, ascites and a 28-lb weight gain. He denied any trauma or surgery in the past. On physical examination, profound pitting oedema (4+) in the extremities and tautness of the abdominal wall with flattening of the umbilicus and positive shifting dullness was noted. Sono-guided paracentesis for symptom relief disclosed a milky appearance of the ascites with a total amount of 2000 mL (Figure 1). Laboratory evaluation showed serum albumin 1.2 g/dL, ascites albumin 0.7 g/dl, serum total cholesterol 653 mg/dL, ascites
cholesterol 25 mg/dL, serum triglyceride 255 mg/dL, ascites triglyceride 8653 mg/dL, 24-h urine protein 27.3 g/day and negative culture and cytology of the ascites analysis. His diagnosis was minimal change disease with nephrotic syndrome based on sono-guided kidney biopsy. Prednisolone (1 mg/kg/day) was administered accordingly, and the patient reported an excellent clinical course without rebound proteinuria or chylous ascites. Chylous ascites, defined by a triglyceride concentration of >110 mg/dL (1.24 mmol/L) in the peritoneal fluid [1], is a peritoneal fluid with milky appearance rich in triglycerides with an estimated incidence of 1 per 20 000 admissions [2]. A variety of causes have been well defined, including liver cirrhosis, malignancies, infectious diseases, traumatic causes, postoperative conditions, congenital diseases, inflammatory processes and miscellaneous causes [3]. Chylous ascites was documented in 52% of patients with nephrotic syndrome based on detection of opalescent effusions [4] rather than by checking the triglyceride level of the peritoneal fluid. The pathogenesis of chylous ascites in nephrotic syndrome is still a mystery, but hypoalbuminaemia-associated bowel oedema with resultant lacteal leakage or malabsorption has been offered as a speculative explanation [4]. The key treatment is to achieve complete remission of the nephrotic syndrome. Conflict of interest statement. None declared.
References 1. Kjeldsberg C, Knight J. Body Fluid: Laboratory Examination of Cerebrospinal, Seminal, Serous and Synovial Fluid. Chicago, IL: ASCP Press, 19933rd edition 2. Press PW, Press NO, Kaufman SD. Evaluation and management of chylous ascites. Ann Intern Med 1982; 96: 358–365 3. Cardenas A, Chopra S. Chylous ascites. Am J Gastroenterol 2002; 97: 1896–1900 4. Lindenbaum J, Scheidt SS. Chylous ascites and the nephrotic syndrome. Report of a case associated with renal vein thrombosis. Am J Med 1968; 44: 830–836 Fig. 1. Peritoneal fluid with milky appearance drained from the patient with an amount around 2000 mL.
Received for publication: 1.1.10; Accepted in revised form: 18.1.10
© The Author 2010. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved. For permissions, please e-mail: [email protected]
