Pleural Effusion in Long-Term Hemodialysis Patients

doi:10.1016/j.transproceed.2007.02.020

Transplantation Proceedings

Volume 39, Issue 4, May 2007, Pages 889-891

https://doi.org/10.1016/j.transproceed.2007.02.020 Get rights and content

Abstract

As a consequence of the expanded use of long-term hemodialysis and extended life spans, complications of chronic renal failure are encountered with an increased frequency among uremic patients. Such patients may develop many thoracic and extrathoracic problems—most frequently uremic pleuritis and pericarditis, uremic pneumonia, infection, and metastatic pulmonary calcification. We retrospectively analyzed the medical records of 257 patients who had received long-term hemodialysis between 1990 and 2006 to better understand the incidence, causes, and clinical features of pleural effusions in this population. The incidence of pleural effusion in hospitalized patients receiving long-term hemodialysis was 20.2% (n = 52; mean age, 55.83 ± 16.56 years; male-to-female ratio, approximately 3:2). Pleural effusion resulted from hypervolemia in 61.5% and was bilateral in 68.8% of patients. Unilateral effusion was present in 25 of 52 (48%) patients. The most frequent causes of unilateral effusion were hypervolemia (n = 9) and parapneumonic effusion (n = 5). Thoracenteses were performed in 14 of the 52 patients in the study group. Of thoracenteses performed, 64.3% of the patients had transudative pleural effusion and 35.7% had exudative effusion. Transudative pleural effusion resulted from hypervolemia in 66.7% and heart failure in 22.2%. Of the patients with transudative effusion, 85.7% were bilateral. The most frequent cause of exudative pleural effusion was uremic pleuritis, which occurred in 40% of the patients. The most common symptom was dyspnea, which occurred in 53.8% of patients. In conclusion, pleural effusions are common in patients receiving chronic hemodialysis. Thoracentesis may be performed in patients with unilateral pleural effusion. Since hypervolemia was the most common cause of pleural effusion, this complication should not be considered an obstacle in renal transplant recipients.

Section snippets

Methods

We reviewed the medical records of 257 hemodialysis patients admitted to the hospital between 1990 and 2006. We identified 52 patients who met the criteria of age older than 16 years, term of dialysis of ≥3 months, and the presence of pleural effusion.

We evaluated patient demographics of age and sex. Chest radiographs were assessed for cardiomegaly (cardiac to thoracic ratio >1.2), evidence of excess extravascular lung water (alveolar or interstitial edema, peribronchial cuffing, Kerley B

Results

The mean age of the patients in the study group was 55 ± 16.5 (mean ± SEM) years. The male-to-female ratio was 3.2. The mean serum albumin level was 3.6 ± 0.5 g/dL.

The incidence of pleural effusions in adult hospitalised patients receiving long-term hemodialysis was 20.2% (52 of 257 patients). The mean hemodialysis period was 83.6 ± 56.6 months. Pleural effusions were secondary to overhydration in 61.5% of the patients. The other causes were heart failure (9.6%), parapneumonic effusions (9.6%),

Discussion

No organ in the chest is spared the negative effects of uremia. The causes of pleural effusion in uremic patients are numerous. In addition to uremic pleuritis, possible pathogeneses include overhydration, cardiac failure, bronchopulmonary bacterial infection or tuberculosis, hypoproteinemia, and hemothorax.⁴

We found that the incidence of pleural effusion in patients receiving long-term hemodialysis admitted to the hospital was 20.2%. Jarratt et al found a 21% incidence of pleural effusion in

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Cited by (40)

Estimation of Pleural Effusion Volume through Chest Ultrasound: Validation of Two Multiplanar Models
2020, Ultrasound in Medicine and Biology
Citation Excerpt :
It is especially useful in people affected by congestive heart failure, who account for the vast majority of transudative pleural effusion cases, to monitor and optimize their response to the therapy (Picano et al. 2018). In people with end-stage renal failure undergoing peritoneal dialysis (Bakirci et al. 2007) or in those with nephrotic syndrome (Light 2006), an overload of pulmonary fluid can have major therapeutic and prognostic implications. For instance, the number of lung comets and the presence of pleural effusion are strong inverse correlates to left ventricular ejection fraction and selected indexes of a diastolic function (Miglioranza et al. 2013).
Computed tomography (CT) scanning is the gold standard when estimating pleural effusion volume; however, the procedure exposes patients to ionizing radiation. Our study was aimed at developing ultrasound-based calculation models that can quantify the volume of pleural effusion in seated patients and validating each model using volumetric chest CT analyses as reference. Our study enrolled 36 hospitalized patients who underwent a chest CT scan and ultrasound, in the seated position, with the aid of a convex probe. To estimate the volume of pleural effusions, we applied one linear and two multiplanar ultrasound-based equations using a CT reconstruction as reference. Testing these models in our validation set (n = 16), we determined that 0.42 was the R² coefficient for the linear equation, and 0.97 and 0.98, respectively, were the R² coefficients for the cylindrical-sector models, and observed that the latter had the lowest dispersion of data and an optimal intraclass correlation coefficient. We then concluded that multiplanar ultrasound-based equations are accurate and reliable in estimating pleural effusions and outperform previously developed equations.
Diagnosis and Management of Pleural Transudates
2017, Archivos de Bronconeumologia
El diagnóstico y tratamiento de los trasudados pleurales ha sido poco estudiado, sobre todo si se compara con el de los exudados, especialmente los malignos, en que diversos ensayos clínicos informan con relativa frecuencia sobre cuál es el manejo óptimo de estos pacientes en la práctica clínica.
La etiología de los trasudados pleurales es amplia, heterogénea, a veces corresponde a enfermedades raras y, en ocasiones, constituye un auténtico reto diagnóstico. El análisis del líquido pleural puede ser una herramienta básica para poder establecer el diagnóstico. El tratamiento debe dirigirse no solamente a la enfermedad subyacente, sino también al propio derrame pleural.
En los casos refractarios al tratamiento médico, habrá que recurrir a procedimientos invasivos como la toracocentesis terapéutica, la pleurodesis con talco, o la inserción de un catéter pleural tunelizado. Sin embargo, en la actualidad, hay muy poca evidencia al respecto y no existen recomendaciones firmes que establezcan en qué situaciones hay que utilizar alguna de estas técnicas invasivas y cuál sería la más eficaz y con menos efectos secundarios para cada una de las enfermedades responsables.
El propósito de este artículo es describir el espectro de enfermedades que causan un trasudado pleural, revisar la aportación diagnóstica del análisis del líquido pleural y poner de manifiesto la escasa evidencia que existe sobre la eficacia de los procedimientos invasivos en el manejo y control del derrame pleural en estos pacientes.
Various clinical trials have been published on the optimal clinical management of patients with pleural exudates, particularly those caused by malignant tumors, while little information is available on the diagnosis and treatment of pleural transudates.
The etiology of pleural transudates is wide and heterogeneous, and they can be caused by rare diseases, sometimes constituting a diagnostic challenge. Analysis of the pleural fluid can be a useful procedure for establishing diagnosis. Treatment should target not only the underlying disease, but also management of the pleural effusion itself.
In cases refractory to medical treatment, invasive procedures will be necessary, for example therapeutic thoracentesis, pleurodesis with talc, or insertion of an indwelling pleural catheter. Little evidence is currently available and no firm recommendations have been made to establish when to perform an invasive procedure, or to determine the safest, most efficient approach in each case.
This article aims to describe the spectrum of diseases that cause pleural transudate, to review the diagnostic contribution of pleural fluid analysis, and to highlight the lack of evidence on the efficacy of invasive procedures in the management and control of pleural effusion in these patients.
Nonmalignant Pleural Effusions: A Prospective Study of 356 Consecutive Unselected Patients
2017, Chest
Pleural effusion secondary to a nonmalignant cause can represent significant morbidity and mortality. Nonmalignant pleural effusion (NMPE) is common, with congestive heart failure representing the leading cause. Despite this, there are limited data on mortality risk and associated prognostic factors.
We recruited 782 consecutive patients presenting to a pleural service between March 2008 and March 2015 with an undiagnosed pleural effusion. Further analysis was conducted in 356 patients with NMPE. Pleural biochemical analysis, cytologic analysis, thoracic ultrasonography, and chest radiography were performed. Echocardiography, CT imaging, radiologically guided biopsy, and medical thoracoscopy were undertaken as clinically indicated. Patients were followed for a minimum duration of 12 months, with the final diagnosis decided through independent review by two respiratory consultants.
Of the 782 patients, 356 were diagnosed with NMPE (46%). These patients had a mean age of 68 years (SD, 17 years) with 69% of them being men. Patients with cardiac, renal, and hepatic failure had 1-year mortality rates of 50%, 46%, and 25%, respectively. Bilateral effusions (hazard ratio [HR], 3.55; 95% CI, 2.22-5.68) and transudative effusions (HR, 2.78; 95% CI, 1.81-4.28) were associated with a worse prognosis in patients with NMPE, with a 57% and 43% 1-year mortality rate, respectively.
This is the largest prospectively collected series in patients with NMPE, demonstrating that cases secondary to organ dysfunction have extremely high 1-year mortality. In addition, the presence of bilateral and transudative effusions is an indicator of increased mortality. Clinicians should be aware of these poor prognostic features and guide management accordingly.
Management of Benign Pleural Effusions Using Indwelling Pleural Catheters: A Systematic Review and Meta-analysis
2017, Chest
Citation Excerpt :
We acknowledge that the major limitation of our study is that the reports included in this meta-analysis are non-randomized-controlled trials with low quality of evidence, but this is currently the best available data on this topic. About 70% of patients with CHF have pleural effusion at some stage of their disease,34 whereas 5% to 10% of patients with portal hypertension and 20% of patients receiving hemodialysis experience pleural effusion.35,36 A small proportion of patients with heart failure experience pleural effusion despite receiving optimal medical care for their CHF.
The indwelling pleural catheter (IPC), which was initially introduced for the management of recurrent malignant effusions, could be a valuable management option for recurrent benign pleural effusion (BPE), replacing chemical pleurodesis. The purpose of this study is to analyze the efficacy and safety of IPC use in the management of refractory nonmalignant effusions.
We conducted a systematic review and meta-analysis on the published literature. Retrospective cohort studies, case series, and reports that used IPCs for the management of pleural effusion were included in the study.
Thirteen studies were included in the analysis, with a total of 325 patients. Congestive heart failure (49.8%) was the most common cause of BPE requiring IPC placement. The estimated average rate of spontaneous pleurodesis was 51.3% (95% CI, 37.1%-65.6%). The estimated average rate of all complications was 17.2% (95% CI, 9.8%-24.5%) for the entire group. The estimated average rate of major complications included the following: empyema, 2.3% (95% CI, 0.0%-4.7%); loculation, 2.0% (95% CI, 0.0%-4.7%); dislodgement, 1.3% (95% CI, 0.0%-3.7%); leakage, 1.3% (95% CI, 0.0%-3.5%); and pneumothorax, 1.2% (95% CI, 0.0%-4.1%). The estimated average rate of minor complications included the following: skin infection, 2.7% (95% CI, 0.6%-4.9%); blockage and drainage failure, 1.1% (95% CI, 0.0%-3.5%); subcutaneous emphysema, 1.1% (95% CI, 0.0%-4.0%); and other, 2.5% (95% CI, 0.0%-5.2%). One death was directly related to IPC use.
IPCs are an effective and viable option in the management of patients with refractory BPE. The quality of evidence to support IPC use for BPE remains low, and high-quality studies such as randomized controlled trials are needed.
Recurrent Brachiocephalic Vein Stenosis as a Cause for Persistent Left-sided Transudative Pleural Effusion in a Hemodialysis Patient
2016, Annals of Vascular Surgery
Citation Excerpt :
Effusion is a common complication seen in patients undergoing renal dialysis.1 In patients receiving long-term hemodialysis, the incidence is reported to be between 16% and 20.2%.2,3 Nonrenal diseases such as congestive heart failure, infections, and neoplasms can also cause effusion in CKD patients.3,4
Effusion is common in dialysis patients. The most common causes include fluid overload due to renal failure and nonrenal causes like congestive heart failure and infection. We here report a case of left side transudative effusion due to brachiocephalic venous stenosis.
A 34-year-old female who had chronic kidney disease V during transplant work-up was found to be having left arm swelling and left transudative effusion. Work-up for transudative effusion did not show any cardiac cause or liver problem. Her dialysis duration was optimized from 2 times a week to 3 times a week for 4 hr and her dry weight was adjusted. Despite adequate dialysis for 1 month, effusion on the left side persisted. She had a previous venoplasty for a stenosis in brachiocephalic vein but restenosis occurred again.
Brachiocephalic vein stenting was performed which successfully lead to resolution of left arm swelling and left effusion. She was later on successfully transplanted.
Brachiocephalic stenosis can cause ipsilateral transudative effusion. Venoplasty and stenting of the brachiocephalic vein lead to complete resolution of effusion.
Pulmonary Complications of Abdominal Diseases
2015, Murray and Nadel's Textbook of Respiratory Medicine: Volume 1,2, Sixth Edition

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Renal transplantationCandidatePleural Effusion in Long-Term Hemodialysis Patients

Abstract

Section snippets

Methods

Results

Discussion

Chest

Chest

Am J Med

Am J Kidney Dis

2000 Registry of Nephrology, Dialysis and Transplantation in Turkey

Renal transplantation
Candidate
Pleural Effusion in Long-Term Hemodialysis Patients