Management of Dry Cough in Dialysis Patients
The best treatment for dry cough in a dialysis patient is to identify and address the underlying cause through a systematic evaluation, starting with switching ACE inhibitors to ARBs if applicable, treating GERD with twice-daily proton pump inhibitors (especially in peritoneal dialysis patients), and optimizing ultrafiltration to address fluid overload. 1
Systematic Diagnostic Approach
First: Evaluate Medication-Induced Cough
- ACE inhibitor-induced cough is the most common and easily reversible cause in dialysis patients 1
- Switch from ACE inhibitors to angiotensin receptor blockers (ARBs), which provide equivalent cardiovascular protection without the cough side effect 1
- This should be your first intervention if the patient is taking an ACE inhibitor 1
Second: Assess for GERD (Particularly Critical in Peritoneal Dialysis)
- Peritoneal dialysis patients have a 3-fold higher risk of chronic cough compared to hemodialysis patients (22% vs 7%), primarily due to gastroesophageal reflux from increased intraperitoneal pressure 1, 2
- Among PD patients with persistent cough, 67% report heartburn versus only 29% of those without cough 2
- Initiate proton pump inhibitor therapy twice daily 1
- Consider reducing dialysate volume if clinically feasible 1
Third: Evaluate for Fluid Overload and Pulmonary Edema
- Pulmonary edema can occur in dialysis patients even without peripheral edema, as it reflects elevated left ventricular end-diastolic pressure independent of peripheral venous congestion 3
- Do not rely on the presence or absence of ankle edema to rule out pulmonary congestion 3
- Assess for orthopnea, jugular venous distension, hepatojugular reflux, pulmonary rales, and S3 gallop 3
- Optimize ultrafiltration during dialysis sessions 1
- Consider diuretic therapy if residual renal function exists 1
- Achieving optimal "dry weight" should be accomplished gradually over 4 to 12 weeks to avoid hypotension and complications 4
Fourth: Consider Bronchospasm/Asthma
- 40% of peritoneal dialysis patients with cough have wheezing versus 16% without cough 1
- Avoid beta-blocking medications in these patients 1
- Initiate inhaled bronchodilators and corticosteroids as appropriate 1
Fifth: Rule Out Infectious Causes
- Tuberculosis and other infections are more common in dialysis patients due to immunosuppression 1
- These require specific antimicrobial therapy and cannot be managed symptomatically 1
Critical Pitfalls to Avoid
- Never use symptomatic cough suppressants as first-line therapy without identifying the underlying cause, as this delays appropriate treatment of potentially serious conditions 1
- Never continue ACE inhibitors if cough is present—switching to ARBs is mandatory 1
- Never assume all cough in dialysis patients is benign—always evaluate for pulmonary edema, which can be life-threatening 1, 3
- Never assume absence of peripheral edema excludes significant volume overload or pulmonary congestion 3
- In patients with bilateral renal artery stenosis or stenosis in a solitary kidney, rapid-onset "flash" pulmonary edema can occur without significant peripheral edema 3
Special Consideration: Distinguishing Procedural from Chronic Cough
If the patient is undergoing pleural effusion drainage, cough during fluid removal indicates excessive negative pleural pressure and impending re-expansion pulmonary edema, requiring immediate cessation of drainage regardless of volume removed 5. However, this is distinct from chronic dry cough, which requires the systematic evaluation outlined above 5, 1.