How to manage a cough in a patient with End-Stage Renal Disease (ESRD)?

Managing Cough in End-Stage Renal Disease Patients

In ESRD patients with cough, systematically evaluate and treat the most common causes using a sequential approach: first discontinue ACE inhibitors if present, then assess for fluid overload and optimize dialysis, followed by aggressive treatment of GERD (especially in peritoneal dialysis patients), and finally address upper airway cough syndrome, asthma, and non-asthmatic eosinophilic bronchitis in that order. 1

ESRD-Specific Considerations First

Dialysis Modality Matters

• Peritoneal dialysis patients develop persistent cough significantly more frequently than hemodialysis patients (22% vs 7%), primarily due to increased intra-abdominal pressure from dialysate causing or worsening GERD 1, 2
• Among PD patients with persistent cough, 67% report heartburn versus only 29% without cough, indicating GERD is a major contributor 2

Assess for Fluid Overload

• Examine for peripheral edema, abnormal lung sounds (crackles), elevated jugular venous pressure, as pulmonary edema is a common cause of cough in ESRD patients regardless of dialysis modality 1
• Review adequacy of dialysis and sodium restriction to prevent fluid overload 1
• If fluid overload is present, intensify dialysis and implement strict sodium and fluid restriction 1

Medication Review is Critical

• Discontinue ACE inhibitors immediately if present, as they are used in 65% of PD patients and 55% of HD patients and commonly cause cough 1, 2
• Switch to an angiotensin receptor blocker if renin-angiotensin system blockade is still indicated 1
• Cough typically resolves within 1-4 weeks of ACE inhibitor cessation, though may take up to 3 months 1

Sequential Treatment Algorithm for Persistent Cough

Step 1: Upper Airway Cough Syndrome (UACS)

• Start with an oral first-generation antihistamine/deconergic combination (e.g., chlorpheniramine with pseudoephedrine) 3
• Newer non-sedating antihistamines are ineffective for cough and should not be used 4

Step 2: Aggressive GERD Management (Especially for PD Patients)

• Initiate high-dose proton pump inhibitor therapy immediately 1, 3
• Implement antireflux diet and lifestyle modifications 3
• Consider adding prokinetic therapy (metoclopramide) if there is little response to PPI alone 3
• Response time is variable: some patients respond within 2 weeks, others may take several months 3
• For PD patients specifically, GERD treatment should be particularly aggressive given the mechanical contribution of dialysate 1, 2

Step 3: Evaluate for Asthma

• Perform spirometry; if normal and asthma still suspected, bronchoprovocation challenge is ideal 3
• If bronchoprovocation unavailable, initiate empiric trial with inhaled bronchodilators and inhaled corticosteroids 3
• For refractory cases, add leukotriene receptor antagonist before escalating to systemic corticosteroids 3, 4
• Consider 5-10 days of oral prednisone 40 mg/day if inhaled therapy fails and no contraindications exist 3

Step 4: Non-Asthmatic Eosinophilic Bronchitis (NAEB)

• Perform induced sputum test for eosinophils if available 3
• If testing unavailable, empiric trial of inhaled corticosteroids 3

Symptomatic Cough Suppression

When Quality of Life is Significantly Affected

• Dextromethorphan 30-60 mg provides effective cough suppression and is safe in ESRD as it does not require significant renal elimination 1
• Codeine and morphine derivatives should be avoided as they accumulate in renal failure 5
• Avoid over-the-counter combination cold medications as they contain ingredients requiring dose adjustment in renal failure 1

Anticholinergic Caution

• Avoid ipratropium bromide or other anticholinergic agents without careful consideration, as elderly ESRD patients are more susceptible to anticholinergic side effects 1

Critical Pitfalls to Avoid

• Never treat only one potential cause - multiple factors often contribute to cough in ESRD patients, requiring sequential and additive therapy 3
• Do not overlook pleural effusions in ESRD patients, as they carry significantly worse outcomes (6-month mortality 31%, 1-year mortality 46%) 1
• Avoid medications with renal excretion pathways to prevent accumulation and toxicity 1
• Do not use midazolam for sedation if needed, as it has delayed metabolism in renal impairment 5

When Standard Approach Fails

If cough persists despite the above interventions:

• Obtain high-resolution CT scan to evaluate for bronchiectasis or occult interstitial disease 3
• Consider bronchoscopy to look for occult airway disease (endobronchial tumor, sarcoidosis, eosinophilic or lymphocytic bronchitis) 3
• Evaluate for uncommon causes: non-acid reflux disease, swallowing disorder, congestive heart failure 3
• Consider referral to a cough specialist before labeling as unexplained cough 3

Palliative Considerations

For ESRD patients with severely limited life expectancy or low quality of life:

• Integrated palliative care should be offered, focusing on symptom control including cough management 3
• Aggressive symptom relief takes priority over diagnostic workup in this population 3