Can a patient with a history of renal failure and undergoing dialysis (dialysis) develop pulmonary edema without presenting with ankle edema?

Pulmonary Edema Without Peripheral Edema in Dialysis Patients

Yes, dialysis patients can absolutely develop pulmonary edema without ankle edema, and this is a critical clinical scenario that should never be dismissed based on the absence of peripheral edema alone. 1, 2

Key Clinical Patterns

Flash Pulmonary Edema (Pickering Syndrome)

• Dialysis patients with bilateral renal artery stenosis or stenosis in a solitary kidney can develop rapid-onset ("flash") pulmonary edema without significant peripheral edema. 1, 3
• This occurs in up to 30% of patients with chronic heart failure who have underlying renal artery stenosis, presenting as acute decompensated heart failure with predominantly pulmonary rather than systemic congestion 1
• The mechanism involves acute pressure overload from severe bilateral renovascular disease, causing pulmonary congestion that develops faster than peripheral fluid accumulation 4, 3

Volume Distribution Patterns

• Pulmonary edema reflects elevated left ventricular end-diastolic pressure and pulmonary capillary wedge pressure, which can occur independently of peripheral venous congestion. 1
• In dialysis patients, fluid can preferentially accumulate in the pulmonary circulation due to left ventricular dysfunction, diastolic dysfunction, or acute pressure changes, even when total body fluid overload is not severe enough to cause ankle edema 5, 6
• Acute pulmonary infection (26% of cases), excessive interdialytic weight gain (25%), and inappropriate dry weight prescription (23%) are leading causes of pulmonary edema in dialysis patients, and these can manifest with isolated pulmonary findings 6

Diagnostic Approach

Clinical Assessment

• Do not rely on the presence or absence of ankle edema to rule in or rule out pulmonary edema in dialysis patients. 1
• The Framingham criteria classify ankle edema as only a minor criterion, while acute pulmonary edema is a major criterion for heart failure diagnosis 1
• Assess for orthopnea, jugular venous distension, hepatojugular reflux, pulmonary rales, and S3 gallop—these are major criteria that can occur without peripheral edema 1

Right Ventricular vs. Left Ventricular Failure

• Right ventricular failure typically presents with peripheral edema, hepatomegaly, and ascites, while left ventricular failure presents with pulmonary congestion. 1, 2
• Dialysis patients can have isolated left-sided failure or acute left ventricular pressure overload causing pulmonary edema without right-sided manifestations 1
• Advanced right ventricular failure signs include elevated jugular venous pressure with prominent V waves and pulsatile liver, but these do not always accompany pulmonary edema 2

Critical Underlying Causes to Evaluate

Renovascular Disease (High Priority)

• In dialysis patients with recurrent pulmonary edema and poorly controlled hypertension, bilateral renal artery stenosis (Pickering syndrome) must be considered. 1, 4, 3
• This affects 94% of patients presenting with this syndrome and requires urgent evaluation for revascularization 4
• Key features include: progressive CKD, severe arterial hypertension, acute decompensated heart failure, and recurrent flash pulmonary edema 1
• A simplified diagnostic strategy using minimal contrast can identify these patients and lead to life-saving revascularization that prevents dialysis dependence 3

Cardiac Dysfunction

• Assess for diastolic dysfunction, left ventricular hypertrophy, and valvular disease (particularly mitral insufficiency), which can cause isolated pulmonary congestion. 1, 5
• Pulmonary edema can occur despite evidence of normal systolic ventricular function in 65% of these patients 4
• Elevated natriuretic peptides (BNP >100 pg/mL or NT-proBNP >300 pg/mL in hospitalized patients) support cardiogenic pulmonary congestion 1

Management Implications

Immediate Treatment

• Phlebotomy can be highly effective for acute pulmonary edema in dialysis patients, with 62% showing marked improvement without requiring intubation or emergent dialysis. 7
• This allows hemodialysis to be delayed by an average of 15.6 hours, with some patients able to wait 24+ hours for their scheduled treatment 7
• Hypertensive patients (62% of cases) tend to normalize blood pressure with phlebotomy, though 19% may develop transient hypotension 7

Long-term Strategy

• Inappropriate dry weight prescription accounts for 23% of pulmonary edema cases in dialysis patients and must be reassessed. 6
• Excessive interdialytic weight gain (25% of cases) requires patient education and dietary sodium restriction 6
• For patients with recurrent episodes despite optimal dialysis management, investigate for renovascular disease, particularly if hypertension is poorly controlled 1, 3

Common Pitfalls

• Never assume that the absence of ankle edema excludes significant volume overload or pulmonary congestion in dialysis patients. 1, 6
• Fluid overload is easily underestimated in dialysis patients and commonly contributes to respiratory symptoms even without peripheral edema 8
• Consider non-volume causes: pulmonary infection (26% of cases), medication-induced bronchospasm from beta-blockers, ACE inhibitor cough, or gastroesophageal reflux from peritoneal dialysate 1, 8, 6
• In patients with unilateral pulmonary edema, consider mitral insufficiency with preferential flow patterns 5