Is perihilar fullness related to End-Stage Renal Disease (ESRD)?

Perihilar Fullness and ESRD: No Direct Relationship

Perihilar fullness is not a recognized manifestation of End-Stage Renal Disease (ESRD). The term "perihilar" refers to the central lung region around the hilum on chest imaging, while ESRD-related thoracic findings are distinctly different and well-characterized.

ESRD-Related Thoracic Manifestations

The actual pulmonary and cardiovascular complications of ESRD that may appear on chest imaging include:

Fluid Overload Manifestations

• Pleural effusions are common in ESRD patients, occurring in approximately 24.7% of patients, with fluid overload being the most common cause (61.5% of cases) 1
• Pulmonary edema from volume overload can present with perihilar or diffuse interstitial patterns, but this represents alveolar edema rather than "perihilar fullness" 1
• Pericardial effusion is frequently observed in ESRD patients and results primarily from volume overload in the modern era, rather than uremic pericarditis 2

Cardiovascular Complications

• Cardiomegaly from uremic cardiomyopathy, characterized by left ventricular hypertrophy and diastolic dysfunction, is a hallmark finding 2
• Volume overload leads to bidirectional changes in LV geometry between concentric and eccentric hypertrophy depending on fluid status and arterial pressure 2

What "Perihilar Fullness" Actually Represents

When radiologists describe "perihilar fullness," they typically refer to:

• Enlarged pulmonary vessels from increased pulmonary blood flow
• Lymphadenopathy in the hilar/mediastinal region
• Early pulmonary edema with vascular congestion
• Mass lesions or infiltrative processes

Clinical Approach When Both Are Present

If a patient with ESRD presents with perihilar fullness on imaging:

Step 1: Assess Volume Status

• Evaluate for fluid overload through clinical examination (jugular venous distension, peripheral edema, lung crackles) 1
• Review dialysis adequacy (Kt/V ≥1.2 for hemodialysis patients) 1
• Consider bioimpedance assessment if available to quantify overhydration 3

Step 2: Optimize Dialysis Management

• Increase dialysis frequency and duration with aggressive ultrafiltration 1
• Implement strict salt and fluid restriction 1
• For peritoneal dialysis patients, use hypertonic exchanges or icodextrin-based solutions 1

Step 3: Investigate Alternative Etiologies

• Rule out infection: ESRD patients have increased susceptibility to infections due to immunosuppression 1
• Consider malignancy: This population carries significant risk for malignancy, and routine cancer screening should guide evaluation 4
• Evaluate for cardiac causes: Heart disease is present in 32.7% of ESRD patients and represents the leading cause of hospitalization (19.1%) and mortality (51.7%) 5
• Obtain CT chest if clinical suspicion exists for infection, malignancy, or other non-volume-related pathology 1

Critical Pitfalls to Avoid

• Do not assume all thoracic imaging abnormalities in ESRD are from volume overload - unilateral findings or those not responding to dialysis intensification warrant further investigation 1
• Recognize the dismal prognosis - ESRD patients with pleural effusions have 6-month and 1-year mortality rates of 31% and 46% respectively, three times higher than the general ESRD population 1
• Maintain high suspicion for cardiovascular disease - cardiovascular conditions are the leading cause of death (51.7%) in ESRD patients 5

Bottom Line

Perihilar fullness is not a characteristic finding of ESRD itself. When present in an ESRD patient, it should prompt evaluation for volume overload (the most likely ESRD-related cause if bilateral and associated with other signs of fluid excess), but alternative diagnoses including infection, malignancy, and primary cardiac disease must be systematically excluded 1, 2, 5.