Can End-Stage Renal Disease (ESRD) cause pleural effusion?

Can ESRD Cause Pleural Effusion?

Yes, ESRD commonly causes pleural effusion, with an estimated prevalence of 24.7% among patients with end-stage renal failure, though the underlying mechanisms are diverse and not all effusions in ESRD patients are directly caused by renal failure itself. 1

Epidemiology and Clinical Significance

• Pleural effusions occur in approximately 21-25% of hospitalized ESRD patients, making this a frequent complication you should actively screen for 1
• The presence of pleural effusion in ESRD patients carries grave prognostic implications, with 6-month and 1-year mortality rates of 31% and 46% respectively—three times higher than the general ESRD population 2
• Most patients experience significant dyspnea and symptom burden, warranting a palliative approach in many cases 2

Multiple Pathophysiologic Mechanisms in ESRD

Fluid overload is by far the most common cause (61.5% of cases), not uraemia itself, which represents only a minority of cases 1. The European Respiratory Society identifies the following mechanisms:

Common Causes:

• Fluid overload (61.5%): Hydrostatic and oncotic imbalances from inadequate ultrafiltration during dialysis 1
• Heart failure (9.6%): Distinct from pure volume overload, though often coexisting 1
• Hypoalbuminemia: Secondary to nephrotic syndrome, causing decreased oncotic pressure 1

Less Common but Important Causes:

• Uraemic pleuritis (16% in older series): Mechanism unknown, but toxins from inadequate dialysis may cause exudative, often hemorrhagic effusions 1, 3
• Peritoneal dialysis-associated pleuro-peritoneal leak: Creates extreme transudates with very low protein (<1 g/dL) and markedly elevated glucose (PF glucose/serum glucose ratio >1) 1, 4, 5
• Urinothorax: Urine diverted into pleural space through diaphragmatic defects, with PF creatinine/serum creatinine >1 1
• Vascular abnormalities: From hemodialysis access complications causing unilateral transudative effusions 1
• Infection or malignancy: Due to immunosuppression inherent to ESRD 1

Critical Diagnostic Pitfalls to Avoid

Do not assume all effusions in ESRD are transudative or bilateral—this is a dangerous oversimplification. 2 The European Respiratory Society emphasizes:

• Light's criteria has poor specificity (44%) in dialysis patients, with high false-positive rates for exudates 2, 6
• Coexisting pneumonia can convert a transudative effusion to exudative in CHF patients, with significantly higher protein, LDH, neutrophil counts, and lower pH 6
• Pleural fluid protein is typically higher in ESRD compared to heart failure alone (23 g/L vs 18 g/L) 2
• Unilateral or exudative effusions mandate investigation for alternative diagnoses including infection, malignancy, vascular complications, or peritoneal dialysis leaks 2

Diagnostic Algorithm

The European Respiratory Society recommends obtaining cross-sectional imaging (CT chest) early when clinical suspicion exists for infection or malignancy, rather than waiting for thoracentesis results 2. When performing thoracentesis:

• Check pleural fluid glucose: Markedly elevated (>serum) suggests PD leak 1, 2, 4, 5
• Check PF creatinine/serum creatinine ratio: >1 indicates urinothorax 1, 2
• Assess for hemorrhagic fluid: Suggests uraemic pleuritis or coagulopathy 1, 3
• Recognize that protein and LDH may be elevated even in volume overload due to ESRD-specific factors 2, 6

Management Approach

First-line treatment is intensifying renal replacement therapy, not pleural intervention, according to the European Respiratory Society 1, 2:

Step 1: Optimize Dialysis and Medical Management

• Increase frequency and duration of dialysis sessions with aggressive ultrafiltration 2
• Implement strict salt and fluid restriction 2
• Maximize diuretic therapy in patients with residual renal function 2
• For PD patients: Use hypertonic exchanges or switch to icodextrin-based solutions 2

Step 2: Therapeutic Thoracentesis

• Perform ultrasound-guided thoracentesis when first-line management fails or urgent symptom relief is needed 2
• Serial thoracentesis provides equivalent symptomatic relief to indwelling pleural catheters and should be the preferred initial pleural intervention 1, 2

Step 3: Refractory Cases

• Consider indwelling pleural catheter (IPC) for patients requiring ≥3 therapeutic thoracenteses 2
• IPCs show significant dyspnea improvement without significant albumin loss in ESRD patients 2
• Chemical pleurodesis or surgical intervention reserved for specific etiologies (uraemic pleuritis, PD leaks) 1, 2

Cause-Specific Management:

• Uraemic pleuritis: Increase RRT intensity, consider tube thoracostomy ±pleurodesis, systemic corticosteroids 1
• PD-associated leak: Alternative RRT mode, pleurodesis, or surgical repair 1, 5
• Urinothorax: Surgical or radiological intervention for anatomical defect 1

Prognostic Context and Palliative Considerations

The European Respiratory Society recommends prioritizing symptom palliation and quality of life over aggressive interventions, given the extremely frail condition and dismal prognosis of ESRD patients with pleural effusions 2. Early involvement of palliative care teams is appropriate for refractory effusions, as treatments are frequently for palliative intent 2.