a 34-year - old female with end - stage renal disease treated by peritoneal dialysis ( pd ) complained of dry cough that had started 1 month previously . the patient 's medications consisted of a calcium channel blocker , angiotensin receptor blocker , erythropoietin , ferrous sulfate , and sevelamer . a chest x - ray showed a pleural effusion on the right side ( fig . a thoracic drainage was placed into the pleural effusion and 1 l of clear liquid was emptied . samples were sent to the chemistry laboratory , to microbiology , and to pathology for further studies . the following results were obtained : glucose , 278 mg / dl ( plasma glucose , 115 mg / dl ) ; total protein < 1.0 g / dl ( total protein in plasma , 7.9 g / dl ) ; lactate dehydrogenase , 49 u / l ( ldh in plasma , 459 u / l ) ; ada , 2.7 iu / l ( 4.3 - 20.3 ) . the effusion contained no malignant cells and the culture grew out no microorganisms . we performed chest computed tomography 1 hour after injecting radiocontrast medium intraperitoneally mixed with 4.25% pd solution . the scan showed focal penetration of intra - abdominal contrast medium via the right hemidiaphragm in the right posterior and lower hemithorax , suggesting a small peritoneopleural fistula ( fig . 2 ) . pleural effusions and hydrothorax are rare complications in pd patients and result from the migration of dialysis fluid under pressure from the peritoneal cavity into the pleural space.1,2 increased intra - abdominal pressure arises either transiently with coughing or straining or permanently from a large volume of pd solution . the mechanism by which peritoneal dialysate transverses the diaphragm is thought to be due to a pleuroperitoneal communication . a sudden increase in intra - abdominal pressure opens a communication between the abdomen and the thorax , allowing pd fluid to leak into the thorax.3 hydrothorax frequently presents as respiratory distress , particularly dyspnea or shortness of breath . a high glucose level in the pleural effusion is an important clue because no other form of hydrothorax has elevated glucose levels.4 pd solution in the thoracic cavity presents a unique situation that occurs only in patients receiving pd . as described in the literature , in most cases , the peritoneopleural fistula is diagnosed by use of scintigraphy . however , scintigraphy is not able to localize a defect in the diaphragm . in the present case , mri has also been attempted to show transdiaphragmatic leakage in a peritoneoflural fistula.5 different therapeutic approaches have been reported . temporary discontinuation of pd , tetracycline instillation into the pleural space , and surgical patch grafting of the diaphragmatic leak have all been described . a novel method may be video - assisted talc pleurodesis.6 this patient received hemodialysis via a permanent catheter after quitting pd .