Pleural Effusions in Hemodialysis Patients
Yes, pleural effusions are a common complication in hemodialysis patients, occurring in approximately 20-25% of hospitalized ESRD patients undergoing chronic dialysis. 1, 2, 3
Epidemiology and Clinical Significance
Pleural effusions affect roughly 1 in 4 hospitalized hemodialysis patients, with prevalence estimates ranging from 20.2% to 24.7% across multiple studies. 1, 2, 3
This is not a benign finding—ESRD patients who develop pleural effusions have a dramatically worse prognosis, with 6-month and 1-year mortality rates of 31% and 46% respectively, which is three times higher than the general ESRD population. 4, 2
Most patients experience significant dyspnea and symptom burden requiring intervention. 4, 2
Common Etiologies in Hemodialysis Patients
Fluid overload is by far the most common cause, accounting for 61.5% of cases, followed by heart failure at 9.6%. 1, 3
Other important causes to consider include:
Uraemic pleuritis (16% of cases)—presents as exudative, often hemorrhagic effusion in underdialyzed patients. 1, 5
Hypoalbuminemia from nephrotic syndrome—causes decreased oncotic pressure leading to transudative effusions. 1, 2
Infection or malignancy—this population has significant immunosuppression risk. 1, 4
Vascular abnormalities from hemodialysis access complications—typically presents as unilateral transudative effusion. 1
Hemorrhagic effusions can occur due to antiplatelet therapy, heparin administration during dialysis, or uremic coagulopathy. 6, 7
Key Clinical Patterns
Bilateral effusions occur in approximately 69% of cases, but unilateral effusions are present in nearly half of patients (48%), warranting investigation for alternative diagnoses beyond simple volume overload. 4, 3
Both transudative (64.3%) and exudative (35.7%) effusions occur, so don't assume all effusions in dialysis patients are transudates from fluid overload. 3
Light's criteria has poor specificity (44%) in the dialysis population with high false-positive rates for exudates, so interpret cautiously. 4, 8
Critical Pitfall to Avoid
Do not assume all pleural effusions in hemodialysis patients are simply from volume overload. The European Respiratory Society emphasizes ruling out infection, malignancy, and other non-fluid overload etiologies before attributing effusions solely to hypervolemia, as this population carries significant risk for both pleural infection and malignancy. 4, 2, 8
When to Investigate Further
Obtain thoracentesis and consider CT chest when:
- Unilateral effusion is present (suggests alternative diagnosis beyond simple fluid overload). 4, 3
- Exudative characteristics are found on initial sampling. 4
- Clinical suspicion exists for infection or malignancy (fever, weight loss, chest pain). 4, 8
- Effusion persists despite 2-3 weeks of optimized dialysis with aggressive ultrafiltration. 4