How to manage pleural effusion, cough, and wheezing in a patient on dialysis (renal replacement therapy)?

From the Guidelines

Managing pleural effusion, cough, and wheezing in a dialysis patient requires a multifaceted approach addressing both the underlying causes and symptoms, with the most recent evidence from 2024 suggesting the use of pleural procedures and renal interventions to control effusions 1. To manage pleural effusion, cough, and wheezing in a patient on dialysis, the following steps should be taken:

• Determine the cause of the pleural effusion through thoracentesis with fluid analysis to distinguish between transudative (often volume overload) and exudative (infection, malignancy) effusions.
• For volume-related effusions, intensify ultrafiltration during dialysis sessions to remove excess fluid, as suggested by the European Respiratory Journal in 2024 1.
• Therapeutic thoracentesis may provide immediate symptom relief if the effusion is large or causing significant respiratory distress.
• For symptomatic management of cough and wheezing, use bronchodilators like albuterol 2.5mg via nebulizer every 4-6 hours as needed, with dose adjustments for renal impairment.
• Low-dose inhaled corticosteroids such as fluticasone 88mcg 1-2 puffs twice daily may help reduce airway inflammation, while avoiding systemic corticosteroids if possible due to fluid retention concerns, as noted in the context of peritoneal dialysis and cough 1.
• Opioid cough suppressants like codeine should be used cautiously with reduced dosing (e.g., 10mg every 6 hours) and close monitoring for accumulation.
• Underlying infections should be treated with appropriate antibiotics adjusted for renal function.
• Regular monitoring of volume status, electrolytes, and respiratory parameters is essential, as is coordination between nephrology and pulmonology teams to balance fluid removal goals with respiratory management, with outcomes measured by patient-reported symptom measures, QoL, frequency and duration of dialysis sessions, volume of fluid removed during dialysis, and pleural procedural complications 1.

From the Research

Management of Pleural Effusion in Dialysis Patients

To manage pleural effusion in a patient on dialysis, it is essential to determine the etiology of the effusion. The following steps can be taken:

• Perform thoracocentesis to analyze the pleural fluid and determine if it is a transudate or exudate 2
• Conduct laboratory tests, including chemical and microbiological studies, as well as cytological analysis, to further understand the etiology of the disease process 2
• Use immunohistochemistry to increase diagnostic accuracy 2
• Manage transudative effusions by treating the underlying medical disorder, such as hypervolemia or heart failure 2, 3
• Manage exudative effusions based on the underlying etiology, such as uremic pleuritis or malignant disease 2, 3

Cough and Wheezing in Dialysis Patients

Cough and wheezing in dialysis patients can be caused by various factors, including:

• Pleural effusion 2, 3
• Gastroesophageal reflux disease (GERD) 4
• Asthma or chronic obstructive pulmonary disease (COPD) 4
• Infection or pneumonia 4, 3
• Uremic pleuritis or pericarditis 3

Treatment Options

Treatment options for pleural effusion in dialysis patients include:

• Thoracentesis to drain the pleural fluid 2, 3
• Pleurodesis to prevent recurrence of malignant effusions 2
• Surgical intervention, such as video-assisted thoracoscopic surgery, to repair any underlying defects or leaks 5, 6
• Conservative management, such as adjusting the dialysis regimen or using diuretics to manage hypervolemia 6, 3
• Antibiotics or other medications to treat underlying infections or conditions 2, 4, 3