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Talc: Is it Safe?

Sheski, Francis D. MD; Mathur, Praveen N. MBBS

doi: 10.1097/01.lbr.0000212562.68274.ed
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Division of Pulmonary and Critical Care Medicine, Indiana University School of Medicine

Pleurodesis is performed to achieve a symphysis between parietal and visceral pleural layers, to prevent accumulation of either air or fluid in the pleural space. Talc is commonly used as a sclerosant because it is the most effective and least expensive agent, but it may induce serious pulmonary complications, such as acute respiratory failure or adult respiratory distress syndrome.1–6 The current article in this edition of JOB by Reichner et al7 reporting a noticeable incidence of renal insufficiency after thoracoscopic talc pleurodesis raises another potential serious complication associated with this procedure, where acute respiratory failure or adult respiratory distress syndrome has been previously reported as a serious, albeit infrequent, talc pleurodesis for a symptomatic, recurrent pleural effusion or for a pneumothorax has been shown to be a successful means to control these problems.8–13 European Respiratory Society/American Thoracic Society guidelines for management of malignant pleural effusion, talc has been considered to the agent of choice as it is effective, cheap, and relatively safe, especially if less than 5 g is used.14 However, respiratory failure has occurred when less than this amount has been used.15 Besides acute respiratory failure, other complications with talc pleurodesis include pain, infection, fever, dyspnea, hypoxemia, unilateral pulmonary edema, pneumonia, tumor implants at the site of the chest tubes, bleeding, and hypotension. Some complications maybe related to sedation or anesthesia or to procedure (video assisted thoracic surgery, thoracoscopy vs. chest tube slurry) more than to talc itself. Renal failure or insufficiency has not been previously reported as associated with talc pleurodesis. This study has some limitations as it is a retrospective case series, patient comorbidities that may put patients at risk for renal injury such as diabetes mellitus, poor cardiac function, and medications which were not described in detail. Nonetheless, based on what is described, there are no clear-cut differences between those who did and those who did not develop renal insufficiency to explain the occurrence. Two patients, who did develop renal failure to the point of needing dialysis but declined, died. Autopsies may have been beneficial to determine the cause of renal failure and to see if talc was in the kidney. In a review of 15 years experience with talc pleurodesis, De Campos indicated renal failure developed in some patients but did not report details.16 Additionally, talc was found in the kidney of 1 patient on autopsy, but whether this patient developed renal failure was not mentioned. Talc instilled into the pleural space has been shown to disseminate to other locations in both humans and in animal models, although to varying degrees. In a rat model Werebe et al17 showed that talc could be found in the kidney, among other organs. However, also using a rat model, Fraticelli et al18 showed that talc minimally disseminated and not to the kidney. Experimental design and talc-used may explain the differing results. Talc size has been demonstrated to influence its ability to disseminate and perhaps to generate an inflammatory response locally or systemically.19–21 Talc compositions varies from manufacturer to another, although all are said to be sterile and asbestos-free. In Europe large particle talc is commonly available but in the United States the manufacturer does provide this detailed information but is presumed to small particle size which is associated with more inflammatory events.20,22 One case reports each of respiratory failure due to doxycycline as sclerosant and renal failure when tetracycline was used as a sclerosant.23,24 No reports of acute respiratory or acute renal failure associated with mechanical abrasion pleurodesis were found. However, may not be most appropriate technique for pleurodesis in malignant pleural effusion.

Although talc is an effective sclerosant and is cheap, this article reinforces the fact that talc has potential serious complications and that the search for an effective but safer agent should continue.

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