From the Guidelines
Uremic pleural effusion should be managed with serial thoracocentesis as the first treatment option, reserving indwelling pleural catheters (IPCs) or attempted talc pleurodesis for refractory cases, according to the most recent guidelines. This approach is based on the limited evidence available, including a recent statement from the European Respiratory Journal 1, which highlights the frailty and poor prognosis of patients with end-stage renal failure (ESRF) and the need for palliative intent in treating pleural effusions. The commonest cause of pleural effusions in this population is fluid overload, but not all patients present with bilateral effusions or transudates, and there is a significant risk of pleural infection or malignancy.
Key considerations in managing uremic pleural effusion include:
- Aggressive medical management or renal replacement therapy (RRT) can adequately treat pleural effusions due to fluid overload, but adverse event rates can limit this approach 1
- Pleural interventions, such as serial thoracocentesis, have been shown to be relatively safe across several observational studies 1
- The choice of pleural intervention should be guided by patient choice and available treatment methods, with similar symptomatic relief achieved by repeat thoracocentesis alone compared to IPCs in observational studies 1
- IPCs or attempted talc pleurodesis should be reserved for refractory cases, given the high adverse event rate and increased drainage volume with IPCs seen in RCTs of benign pleural effusions 1
In clinical practice, it is essential to prioritize the management of uremic pleural effusion based on the individual patient's needs and prognosis, taking into account the potential risks and benefits of different treatment options. Regular monitoring of kidney function, electrolytes, and fluid status is crucial for effective management, and cross-sectional imaging should be considered early in the diagnostic pathway if there is clinical suspicion of pleural infection or malignancy 1.
From the Research
Definition and Causes of Uremic Pleural Effusion
- Uremic pleural effusion is a relatively common occurrence in patients with end-stage renal disease (ESRD) 2.
- It is caused by uremia, which can lead to the development of hemorrhagic pleural fluid collections in patients who are underdialyzed 2.
- The development of uremic pleural effusions is associated with serosal injury and defective platelet function, leading to transudation of fluid into the pleural space 2.
Clinical Features and Diagnosis
- Patients with uremic pleural effusion may present with dyspnea, cough, weight loss, anorexia, chest pain, and fever 3.
- Pleural fluid analysis may show a serosanguineous or hemorrhagic appearance, with elevated protein and lactic dehydrogenase (LDH) levels, indicating an exudate 4.
- Thoracentesis and pleural biopsy may be necessary to diagnose uremic pleural effusion and rule out other causes of pleural effusion 5, 4.
Treatment and Management
- Treatment of uremic pleural effusion typically involves intensifying dialysis to improve uremic symptoms 2.
- Thoracentesis and chest tube insertion may be necessary to drain the pleural effusion and provide symptomatic relief 5, 3.
- Pleural decortication may be necessary in some cases to manage uremic pleuritis 3.
- The outcome of uremic pleuritis can be improved with continuation of hemodialysis and other interventions 3.
Incidence and Prevalence
- The incidence of pleural effusion in patients receiving long-term hemodialysis is approximately 20.2% 6.
- Uremic pleuritis is a common cause of pleural effusion in patients with chronic hemodialysis, with a rate of 23.7% 3.
- Other frequent etiologies of pleural effusion in patients with chronic hemodialysis include parapneumonic effusion, cardiac failure, and tuberculosis 6, 3.