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1 대한내과학회지 : 제 77 권제 6 호 2009 증례 Icodextrin 과포비돈액반응으로진단한복막투석액의흉강누출 1예 1 동아대학교의과대학내과학교실, 2 부산의료원신장내과 유현승 1 남현경 2 안원석 1 김성은 1 김기현 1 case of hydrothorax caused by peritoneal dialysate leakage diagnosed using the reaction between icodextrin and povidone-iodine Hyun Seung Yoo, M.D. 1, Hyun Kyung Nam, M.D. 2, Won Seok n, M.D. 1, Seung Eun Kim, M.D. 1, and Ki Hyun Kim, M.D. 1 1 Department of Internal Medicine, Dong- University College of Medicine; 2 Division of Nephrology, usan Medical Center, usan, Korea Hydrothorax occurs as a complication of peritoneal dialysis in about 2% of cases. When a pleural effusion occurs, the effusion should be analyzed as part of the differential diagnosis. hydrothorax due to peritoneal dialysate leakage can be suspected based on higher glucose and lower protein content compared with serum. Computed tomography (CT) peritoneography, peritoneal scintigraphy, and magnetic resonance peritoneography are safe, accurate, and reliable methods for diagnosing hydrothorax. Here, we report a case of hydrothorax associated with dialysate leakage that could not be confirmed using standard CT peritoneography. We confirmed the leakage by observing the change in color to black in a test that involved adding povidone-iodine to the pleural fluid obtained by thoracentesis after a cycle of peritoneal dialysis with icodextrin solution. We propose using the icodextrin-povidone reaction as a test for hydrothorax caused by dialysate leakage. (Korean J Med 77: , 2009) Key Words: Hydrothorax; Peritoneal dialysis; Icodextrin; Povidone-iodine 서론복막투석환자의약 2% 에서투석액의흉강누출로흉수가발생하며, 경증의흉수는증상이없어실제빈도는더높을수있다 1,2). 흉강누출이확인되면흉수검사를시행하여다른원인들을감별해야하며 3,4) 혈청에비해상대적으로높은농도의포도당과낮은농도의단백질이보일때는투석 액의흉강누출을의심해야한다 1). 진단을위해복강전산화단층촬영 (CT peritoneography) 5), 복강내방사선동위원소촬영 (peritoneal scintigraphy) 6), 복강자기공명촬영 (MR peritoneography) 7) 등의조영제를이용한영상진단법이비교적안전하고정확하며빠른진단방법으로알려져있다. 메틸렌블루와인디아잉크등의염료를복강내에주입한후흉강천자를통해누출을확인할수있으나심한통증을일으킬 Received: ccepted: Correspondence to Seung Eun Kim, M.D., Department of Internal Medicine, Dong- University College of Medicine, 1 3-ga, Dondaesin-dong, Seo-gu, usan , Korea sekim@dau.ac.kr

- The Korean Journal of Medicine: Vol. 77, No. 6, 2009 - 증 례 Figure 1. The simple chest X-ray shows a pleural effusion in the right chest. 수있어서잘사용하지않는다 8).

환자 : 양 복, 여자 44세주소 : 호흡곤란과거력및가족력 : 당뇨와갑상선기능저하증현병력 : 임신성당뇨병의병력이있는환자로 2개월전부터복막투석을시작하였다. 내원 2주전부터시작된호흡곤란과기침때문에촬영한흉부사진에서우측폐의흉수를발견하였다.

검사소견 : 말초혈액검사상백혈구 7,840/mL, 혈색소 10.3 g/dl, 혈소판 293,000/mL였으며일반화학검사상혈청총단백량 5.1 g/dl, 혈청알부민 2.8 g/dl, 혈당 204 mg/dl, LDH 468 U/L, NP 229 pg/ml였다. 흉수검사상색깔은황색이었고, ph 7.

2 - The Korean Journal of Medicine: Vol. 77, No. 6, 증 례 Figure 1. The simple chest X-ray shows a pleural effusion in the right chest. 수있어서잘사용하지않는다 8). 저자들은복강전산화단층촬영 (CT peritoneography) 으로진단할수없었던투석액누출에의한흉수를 icodextrin과포피돈액의화학반응을이용하여진단한후치료한 1예를보고한다. 환자 : 양 복, 여자 44세주소 : 호흡곤란과거력및가족력 : 당뇨와갑상선기능저하증현병력 : 임신성당뇨병의병력이있는환자로 2개월전부터복막투석을시작하였다. 내원 2주전부터시작된호흡곤란과기침때문에촬영한흉부사진에서우측폐의흉수를발견하였다. 진찰소견 : 입원시혈압은 150/90 mmhg, 맥박수 90회 / 분, 호흡수 28회 / 분, 체온 36.5 였고, 양하지에함몰부종이있었다. 우측폐야의호흡음은감소되었으며타진시둔탁음이들렸다. 복부는팽만되어있었으나, 압통이나촉진되는종괴는없었으며도관출구부위의이상소견은없었다. 검사소견 : 말초혈액검사상백혈구 7,840/mL, 혈색소 10.3 g/dl, 혈소판 293,000/mL였으며일반화학검사상혈청총단백량 5.1 g/dl, 혈청알부민 2.8 g/dl, 혈당 204 mg/dl, LDH 468 U/L, NP 229 pg/ml였다. 흉수검사상색깔은황색이었고, ph 7.5, 적혈구수 0/mL, 백혈구수 306/mL ( 중성구 0%, 임파구 57%), 포도당 227 mg/dl, 단백질 0.3 g/dl, 알부민 0.1 g/dl, LDH 40 U/L, D 1 IU/L였고, 그람염색및균배양검사, Tb-PCR 은음성이었다. 방사선검사및진단검사소견 : 내원시흉부사진에서우측폐의흉수소견이보였다 ( 그림 1). 조영제를섞은투석액을주입하고 2, 4시간후촬영한영상 ( 그림 2, 2) 에서는조 Figure 2. (, ) Contrast CT peritoneography shows a large pleural effusion on the right side without enhancement

povidone-iodine - Figure 3. Povidone mixed with 1.

Povidone mixed with a pleural effusion sample from the patient. Figure 4.

thoracic cavity with progressive accumulation over time. 영제의누출을확인할수없었다.

3 - Hyun Seung Yoo, et al. Peritoneal dialysate leakage diagnosed by reaction between icodextrin and povidone-iodine - Figure 3. Povidone mixed with 1.50% Physioneal (); Povidone mixed with icodextrin (). Povidone mixed with a pleural effusion sample from the patient. Figure 4. (, ) Tc-99m peritoneography shows migration of the radiotracer into the right thoracic cavity with progressive accumulation over time. 영제의누출을확인할수없었다. Icodextrin 2 L를복강내에주입하고 4시간후천자로얻은흉수에포비돈용액을반응시켜변색반응을관찰하였다 ( 그림 3, 3). 이후 5 mci 의 99m Tc albumin colloid를투석액 2 L에섞어복강내에주입하 고, 15분, 4시간후촬영한영상에서우측흉강으로투석액누출을확인하였다 ( 그림 4, 4). 치료및경과 : 복막투석의흉강누출을확인한후복막투석을중단하고경정맥도관을통한혈액투석을시행하면서

4 - 대한내과학회지 : 제 77 권제 6 호통권제 592 호 횡격막결손의자연적인봉합을기대하였으나 2주후시험적인복막투석시다시흉강누출이있었다. 흉관을삽입하고, 3일후 OK KE를한차례주입하였다. 2주후 1.50% 투석액 1 L로투석을시행하였으나흉강누출소견이더이상없어복막투석을재개하였으며현재 8개월째재발소견없이경과관찰중이다. 고찰복막투석환자에서투석액의흉강누출은복막투석의비감염성합병증으로 1967년 Edwrd 9) 등이보고한이래점차발생이늘고있으며 10), Chow 등은 10% 가량높은유병률 11) 을보고하였으나 26% 에서무증상의흉수를보인다고하여실제유병률은더높을것으로생각한다 1). 복막투석시흉강으로의투석액누출기전에대하여는두가지설이있다. 투석액누출에의한흉수발생이복막투석조기에발생하는경우가많으므로흉강- 복강사이의선천적인결함부위가원인일수있다 12). 또한, 복막투석을시작하고, 시간이지나나타나는흉수의경우는지속적으로증가된복압에의해횡격막의교원섬유들이파괴되어발생하기도한다 1,13). 본증례에서는복막투석시작 2개월만에흉수가발생하여두가지기전중어느쪽도배제하기어렵다. 흉수가발견되면흉수검사를시행하여일반적인감염이나종양, 심부전, 세포외액의증가, 저단백혈증, 결핵등의원인들을감별해야하며 3,4), 혈청에비해상대적으로높은농도의포도당과낮은농도의 LDH 소견의여출액을보일때는복막투석액의흉강누출을의심해야한다 1). 확진을위해가장널리쓰이는방법으로복강전산화단층촬영 5), 복강내방사선동위원소촬영 6), 복강자기공명촬영 7) 등의조영제를이용한영상진단법이비교적안전하고정확하며빠른진단방법으로알려져있다. 본증례에서는감별진단을위한검사들에서다른원인을생각할만한소견이없으면서흉수에서혈청에비해상대적으로포도당농도가높아투석액의흉강누출을의심하였다. 진단을위해조영제사용복강전산화단층촬영을하였으나누출소견은없었다. 복강내방사선동위원소촬영으로확인하려하였으나촬영하는동안환자가누워있지못하여시행할수없는상황이어서 icodextrin과포비돈액의화학반응을이용하기로하였다. lack line sign 은포비돈과녹말간의상호작용을 14) 의미하는것으로, 포도당중합체인 icodextrin이녹말성분과아주유사하여 icodextrin과포비돈액을섞으면흑청색으로변색 을하게된다. 저자들은시험관에 1.50% 포도당투석액과 icodextrin액을각각담고스포이드를이용하여포비돈액을각각두방울씩떨어뜨린후 icodextrin액만흑청색으로변색하는것을시험하였다. 그다음저자들은 icodextrin 투석액을환자의복강에주입하여시간경과후천자로얻은흉수와포비돈액을반응시켜흑청색으로변색하는것을확인하여복막투석액의흉강누출로진단하였다 ( 그림 3, 3). 이후환자증상이호전되면서복강내방사선동위원소촬영이가능하였고, 역시흉강누출을확인할수있었다 ( 그림 4, 4). 복강내방사선동위원소촬영은병원의여건에따라항상가능한검사는아니다. 따라서복강전산화단층촬영이표준적인진단법이라할수있는데, 본증례에서평소복막투석액의흉강또는복벽으로의누출등을진단하던촬영방법을따랐으며조영제주입후충분한운동과시간경과등의조건을지켜촬영하였는데도복강전산화단층촬영으로흉강누출을확인할수없었다. 복강전산화단층촬영에서발견하지못하였던이유를정확히알수없으나 OK 432를사용한화학적흉막유착술을한차례만시행하고도완치된점을감안하면흉강- 복강사이결손부가아주작았을가능성을추측해볼수있다 15). 저자들은본증례의경험을통해방사선검사에서누출을증명하지못한경우라도흉수가찬복막투석환자에서투석액의흉강누출을배제할수없다는교훈을얻었으며향후흉강누출이의심되나방사선검사에서증거를찾기어려운경우 icodextrin과포비돈액의화학적변색반응을이용한진단을고려할것을제안한다. 요약복막투석액의흉강누출은복막투석환자에서그다지흔하지않은비감염성합병증이다. 보통조영제를사용하는복강전산화단층촬영으로비교적쉽게진단할수있다. 저자들은조영제사용복강전산화단층촬영으로진단할수없었던복막투석액의흉강누출을 icodextrin과포비돈액의화학적변색반응으로진단하여화학적흉막유착술로치료한경험 1예를보고한다. 본증례를통해복강전산화단층활영등의방사선검사에서음성소견이라도복막투석환자의흉강누출가능성을배제하지못한다는사실을알수있으며, 흉강누출이의심되나방사선검사에서증거를찾기어려운경우 icodextrin과포비돈액의화학적변색반응을이용한진단을고려할것을제안한다

5 - 유현승외 4 인. 화학적변색반응으로진단한투석액의흉강누출 - 중심단어 : 흉수 ; 복막투석 ; Icodextrin; 포비돈액 REFERENCES 1) Nomoto Y, Suga T, Nakajima K, Sakai H, Osawa G, Ota K, Kawaguchi Y, Sakai T, Sakai S, Shibata M. cute hydrothorax in continuous ambulatory peritoneal dialysis: a collaborative study of 161 centers. m J Nephrol 9: , ) Garcia Ramon R, Carrasco M. Hydrothorax in peritoneal dialysis. Perit Dial Int 18:5-10, ) Tsunezuka Y, Hatakeyama SI, Iwase T, Watanabe G. Video assisted thoracoscopic treatment for pleuroperitoneal communication in peritoneal dialysis. Eur J Cardiothorac Surg 20: , ) Huang JJ, Wu JS, Chi WC, Lan RR, Yang LF, Chiu NT. Hydrothorax in continuous ambulatory peritoneal dialysis: therapeutic implication of Tc-99m M peritoneal scintigraphy. Nephrol Dial Transplant 14: , ) ernardini J. Peritoneal dialysis catheter complication. Perit Dial Int 16(Suppl 1):S468-S471, ) Juergensen PH, Rizvi H, Caride VJ, Kliger S, Finkelstein FO. Value of scintigraphy in chronic peritoneal dialysis patients. Kidney Int 55: , ) Prischl FC, Muhr T, Seiringer EM, Funk S, Kronabethleitner G, Wallner M, rtmann W, Kramar R. Magnetic resonance imaging of the peritoneal cavity among peritoneal dialysis patients, using dialysate as contrast medium. J m Soc Nephrol 13: , ) Kennedy JM. Procedures used to demonstrate a pleuroperitoneal communicaton: a review. Perit Dial ull 3: , ) Edward SR, Unger M. cute hydrothorax: a new complication of peritoneal dialysis. JM 199: , ) Duffy JP, llen SM, Mattews HR. Hydrothorax due to dialysate leakage. Clin Nephrol 42:65, ) Chow CC, Sung JY, Cheung CK, Hamilton-Wood C, Lai KN. Massive hydrothorax in continuous ambulatory peritoneal dailysis: diagnosis, management and review of the literature. N Z Med J 101: , ) lberts WM, Salem J, Solomon D, oyce G. Hepatic hydrothorax: cause and management. rch Intern Med 151: , ) Green, Logan M, Medawar W, McGrath F, Keeling F, Carmody M, Donohoe J. The management of hydrothorax in continuous ambulatory peritoneal dialysis. Perit Dial Int 10: , ) Robertson S, Huxtable H, lakemore C, Williams G, Donovan KL. The icodextrin black line sign. Perit Dial Int 21: , ) Sung S, Ko GJ, Kim MK, Kim JY, Jo SK, Cho WY, Kim HK. Chemical pleurodesis as a treatment for hydrothorax complicating peritoneal dialysis. Korean J Nephrol 24: ,

<B0EDBDC5C0C7B4EB20C7D0BCFAC1F B1C731C8A32D E362E333028C3D6C1BE292E687770>

<B0EDBDC5C0C7B4EB20C7D0BCFAC1F B1C731C8A32D E362E333028C3D6C1BE292E687770> http://dx.doi.org/10.7180/kmj.2014.29.1.53 KMJ Case Report A Case of Hydrothorax Aggravated by Peritoneal Dialysate Leakage in Compensated Liver Cirrhosis Patient with Ascites Gain You, Ho Sik Shin, Yeon