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Hydrothorax is an uncommon but established complication of peritoneal dialysis, usually arising from pleuroperitoneal leak. There is currently no consensus on definitive testing or management. Thoracentesis, sclerosing agents, and either temporary or permanent discontinuation of peritoneal dialysis in favor of hemodialysis are often considered. We report an unusual case of right-sided PD-associated hydrothorax in a 54-year-old female with a history of hypertension and anemia, who presented without chest pain or dyspnea but rather with fatigue and syncope. We review the current literature on this etiology regarding underlying causes, as well as best practices for diagnosis and treatment.