To the Editor, Nephrogenic ascites is a rare, challenging complication of end-stage renal disease, most often seen in patients undergoing long-term hemodialysis. It is often a diagnosis of exclusion and is associated with a poor prognosis, with average survival ranging from 7 to 11 months and approximately half of patients dying within 15 months of diagnosis.1 We present a case of refractory nephrogenic ascites that resolved spontaneously following renal transplantation, highlighting a potential curative role of renal transplantation in such challenging presentations. A 36-year-old male with end-stage renal disease on maintenance hemodialysis presented to us with progressive abdominal distension for 2 months. Extensive evaluation ruled out hepatic, pancreatic, cardiac, infectious, and malignant causes, and a diagnosis of nephrogenic ascites was made. Extensive evaluation ruled out hepatic, pancreatic, cardiac, infectious, and malignant causes, and a diagnosis of nephrogenic ascites was made Table 1. He was managed with strict salt and fluid restriction, a high-protein diet (1.2–1.3 g/kg/day), intensive hemodialysis (four to five sessions per week) with probing the dry weight, and intravenous albumin infusions. In addition to these interventions, he underwent multiple therapeutic paracenteses and pigtail catheter drainage. However, these measures only provided minimal clinical benefit. Given the patient’s clinical status and lack of response to conservative management, he was considered for and subsequently underwent kidney transplantation from a living related donor. Remarkably, his ascites resolved completely following transplantation. He was doing well in the 6-month follow-up, with excellent graft function and no recurrence of ascites.Table 1: Laboratory investigations (before renal transplantation)Terms used synonymously with nephrogenic ascites include dialysis-related ascites, hemodialysis-associated ascites, nephrologous ascites, and idiopathic ascites. The underlying cause of nephrogenic ascites remains unclear, but it may stem from factors such as inadequate nutrition and patient nonadherence to dialysis.2 Other potential contributors include changes in peritoneal membrane permeability, increased fluid intake, heart failure, and reduced lymphatic drainage or absorption, all of which can disrupt the regulation of peritoneal fluid dynamics and lead to the accumulation of protein-rich fluid in the peritoneal cavity.3 Patients usually present with low serum-ascites albumin gradient, low white blood cell, and high protein ascites.4 Conservative management (salt and fluid restriction, albumin infusion, and frequent paracentesis) is the mainstay of treatment, with transplantation as the only definitive option;5 this case adds to the limited evidence. Given the morbidity and management challenges associated with this condition, clinicians should maintain a high index of suspicion in dialysis patients with unexplained ascites and consider early evaluation for transplantation. Declaration of patient consent The authors certify that patient consent has been taken for participation in the study and for publication of clinical details and images. Patients understand that the names, initials would not be published, and all standard protocols will be followed to conceal their identity. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Yelavarthy et al. (Thu,) studied this question.