Can end-stage renal disease (ESRD) and fluid overload cause pleural effusion?

From the Guidelines

Yes, end-stage renal disease (ESRD) and fluid overload can definitely cause pleural effusion. In ESRD, the kidneys lose their ability to filter waste products and regulate fluid balance in the body, leading to fluid accumulation in various parts of the body, including the pleural space surrounding the lungs 1. This type of pleural effusion is typically classified as a transudative effusion, characterized by low protein content. Fluid overload in ESRD patients occurs because they cannot excrete enough water and sodium, leading to increased hydrostatic pressure that forces fluid into the pleural space.

Key Points to Consider

• Patients with ESRF who manifest a pleural effusion tend to have a poorer prognosis, and a greater degree of cardiac comorbidity and death from cardiovascular disease, when compared to those without pleural effusion 1.
• Management typically involves dialysis to remove excess fluid, sodium restriction (usually 2-3 grams daily), and sometimes diuretics like furosemide (if residual kidney function exists) 1.
• Thoracentesis may be needed for large effusions causing respiratory distress, but addressing the underlying fluid overload through proper dialysis is the definitive treatment 1.
• Without adequate fluid removal, pleural effusions will likely recur despite temporary drainage procedures.

Treatment Approach

• The choice of pleural intervention is guided by patient choice and available treatment methods, but similar symptomatic relief has been achieved by repeat thoracocentesis alone when compared with indwelling pleural catheters (IPCs) in observational studies 1.
• Given the high adverse event rate and increased drainage volume with IPCs seen in RCTs of benign pleural effusions, serial thoracocentesis is often offered as the first treatment option, with IPCs or attempted talc pleurodesis reserved for refractory cases 1.

From the FDA Drug Label

ADVERSE REACTIONS Adverse reactions are categorized below by organ system and listed by decreasing severity. Other Reactions

1. Hyperglycemia
2. Glycosuria
3. Hyperuricemia
4. Muscle spasms
5. Weakness
6. Restlessness
7. Urinary bladder spasm
8. Thrombophlebitis
9. Transient injection site pain following intramuscular injection
10. Fever

The FDA drug label does not answer the question.

From the Research

Causes of Pleural Effusion in End-Stage Renal Disease (ESRD)

• Pleural effusion is a common complication in patients with ESRD, with a reported incidence of 20.2% in hospitalized patients receiving long-term hemodialysis 2.
• The causes of pleural effusion in ESRD patients can be diverse, including:
  • Hypervolemia (fluid overload) 2
  • Uremic pleuritis 3, 2
  • Infection (e.g., tuberculosis, pneumonia) 4
  • Malignancy (e.g., lung cancer, renal carcinoma) 4
  • Collagen diseases 4
  • Hepatic abscess 4
  • Pulmonary thromboembolism 4
  • Idiopathic causes 4

Role of Fluid Overload in Pleural Effusion

• Fluid overload (hypervolemia) is a common cause of pleural effusion in ESRD patients, accounting for 61.5% of cases in one study 2.
• The development of pleural effusions in ESRD patients can be attributed to uremia-associated serosal injury, allowing transudation of fluid into the pleural space 5.

Characteristics of Pleural Effusion in ESRD

• Pleural effusions in ESRD patients can be transudative or exudative, with transudative effusions often resulting from hypervolemia or heart failure 2.
• Exudative pleural effusions can be caused by uremic pleuritis, infection, or malignancy 3, 2, 4.
• The pleural fluid can appear serosanguineous or hemorrhagic, and may contain a predominance of lymphocytes or neutrophils 3.