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Acute pulmonary edema in chronic dialysis patients admitted into an intensive

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Article  in  Nephrology Dialysis Transplantation · May 2011

DOI: 10.1093/ndt/gfr290 · Source: PubMed

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Nephrol Dial Transplant (2012) 27: 603–607
doi: 10.1093/ndt/gfr290
Advance Access publication 26 May 2011

Acute pulmonary oedema in chronic dialysis patients admitted into an

intensive care unit

Marie-Patrice Halle1,2, Alexandre Hertig1, Andre Pascal Kengne3, Gloria Ashuntantang4,5, Eric Rondeau1
and Christophe Ridel1
1
Department of Nephrology Intensive Care and Transplantation, Tenon Hospital, Paris, France, 2Department of Internal Medicine,
General Hospital, Douala, Cameroon, 3The George Institute for International Health, The University of Sydney, Sydney, Australia,
4
Department of Internal Medicine and specialties, Faculty of Medicine and Biomedical Sciences, University of Yaounde I, Yaounde,

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Cameroon and 5Department of Medicine, General Hospital of Yaounde, Yaounde, Cameroon
Correspondence and offprint requests to: Marie-Patrice Halle; E-mail: patricehalle@yahoo.fr

Abstract
Background. Acute pulmonary oedema (APO) in patients
undergoing chronic dialysis (CD), a common cause of hos-
pital admission in this population, is poorly documented.
The objective of this study was to determine the causes,
profile, clinical course and outcomes of APO in CD pa-
tients admitted in an intensive care unit (ICU).
Methods. Medical charts of all CD patients consecutively
admitted for APO in the renal ICU of the Tenon Hospital
(Paris, France) between January 2000 and December 2007
were considered. Data collection included patient charac-
teristics, etiologic factors for chronic renal failure and co-
morbidities, past history of APO, precipitating factors,
clinical evolution and outcomes.
Results. Of the 112 files considered, 102 (65% men) were
included in the final analysis. Patients were aged 20–88
years and had been dialysed for a median duration of 2
years. Hypertension (36.3%), chronic glomerulonephritis
(25.5%) and diabetes mellitus (17.6%) were the main etio-
logic factors of chronic renal failure; 38.2% had a past
history of APO. Acute pulmonary infection (26%), exces-
sive interdialytic weight gain (25%) and inappropriate dry
weight prescription (23%) were the leading causes of APO.
The duration of hospitalization was <4 days in 60% of
participants. Nine deaths (four being of cardiac origin)
were recorded. Being referred from another hospital service
was the main predictor of death.
Conclusions. APO fuelled in part by chest infection,
excessive interdialytic weight gain and inappropriate dry
weight are important causes of hospitalization in CD
patients. Mortality is high among those referred from other
services usually in critical conditions.
Keywords: acute pulmonary oedema; chronic dialysis; intensive care
unit; outcome
Introduction
The global population of individuals with end-stage renal
disease (ESRD) has rapidly increased over the past two
decades [1, 2]. In Europe, for instance, available data
indicate an increase in both the incidence and the preva-
lence of chronic dialysis (CD) patients at the average
annual pace of 4% [2]. CD patients are at increased risk
of multiple organ dysfunctions resulting from pre-existing
medical conditions and secondary complications of renal
replacement therapy. As a consequence, they are frequently
hospitalized, particularly in intensive care units (ICUs). In a
recent study, it was estimated that 2% of CD patients per
year would require an ICU admission [3]. The evolution of
these patients in ICU is characterized by a significant mor-
bidity and mortality. Cardiovascular diseases including
acute pulmonary oedema (APO) are the most common
causes of hospital admission in CD patients [4, 5]. The
dramatic presentation of APO usually calls for emergency
care, usually in ICU. Available studies of APO have mostly
been conducted in acute coronary care units [6-10]. The
few reports about CD patients in ICU have generally
focused on the reason for their admission and on their
clinical course [3, 11, 12] but not specifically on APO.
The main purpose of this study was to determine the
causes of APO in CD patients admitted in an ICU and
second to determine the clinical course and outcomes.
Materials and methods
The study was conducted in the renal ICU and Transplantation Unit of Tenon
Hospital in Paris, France. This department is a referral centre with a capacity
of 12 ICU beds, a group of critical care nephrologists. A mean 500 admissions
are recorded per year. Medical records of CD patients admitted from January
2000 to December 2007 were retrospectively reviewed for evidence of APO
as reason for admission. Final diagnosis of APO was based on a set of clinical
and radiological findings such as onset of severe cough, dyspnoea, respiratory
distress and clinical and radiological signs of pulmonary congestion. Patients
were excluded if they were not already on chronic dialysis at the time of

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604 M.-P. Halle et al.
50

45

40
Monday-Wednesday-Friday
Percentage of patients ( )

35
Tuesday-Thursday-Saturday
30
Total
25

20

15

10

0
Monday Tuesday Wednesday Thursday Friday Saturday Sunday
Admission day

Fig. 1. Days of admission of patients (overall and according their past dialysis schedules: either Monday, Wednesday and Friday or Tuesday, Thursday

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and Saturday). P-value <0.001 for the distribution.

Hypertension 76
Pulmonary oedema 39
Ischaemic cardiomyopathy 31
Heart failure 29
Diabetes mellitus 28
Cancers 16
Rythmic disorders 16
Others 15
Lower limbs arteriopathy 13
Dyslipidaemia 11
Smoking 10
Valvulopathy 10
Chronic obstructive bronchopneumopathy 7
Cerebrovascular accident 7
HIV inf ection 4

0 10 20 30 40 50 60 70 80
Number of patients

Fig. 2. Distribution of past medical events and risk factors.

admission (for a minimum of 3 months). Data were collected on patient
characteristics at baseline, including demographics, day of admission and
reasons for admission, primary cause of ESRD and duration of dialysis
dependence as well as prior dialysis schedule (Monday, Wednesday and
Friday versus Tuesday, Thursday and Saturday), compliance with dialysis
and chronic treatment, causes of pulmonary oedema, biological, radiologic
and echocardiographic parameters, treatment and outcome.
Definitions
Routine outpatient dialysis discontinuation was used to characterize pa-
tients who had missed at least the last scheduled dialysis session in their
usual care centre prior to the admission in our ICU. Medication discontin-
uation was used for patients who stopped their chronic medications in-
cluding diuretics and blood pressure-lowering medications for at least 7
days prior to their admission of APO. Non-compliance with dialysis, diet
and medications were used to characterize patients who followed the
above irregularly. Excess interdialytic weight gain was diagnosed in pa-
tients with excessive weight gain between dialysis sessions, in the pres-
ence of adequate volaemic control in dialysis and appropriate target
weight. Inappropriate target weight assessment was defined in patients
with fluid congestion resulting from ineffective ultrafiltration during
dialysis. Lower respiratory chest infection was based on (i) fever, bio-
logical inflammatory syndrome, asymmetrical basal lung opacities on
chest X-ray, together with typical radiological signs of pulmonary oedema
before dialysis and (ii) resolution of the radiological signs of pulmonary
oedema following dialysis and of the basal asymmetrical opacities only
after treatment with antibiotics. Precipitating cardiac events were diag-
nosed in the presence of positive biomarkers (troponin).
Data were analysed with the use of SPSS version 9.0.0 for Windows.
Comparisons used chi-squared test and equivalents for categorical variables
and t-test and Mann–Whitney U-test for quantitative variables. Logistic
regressions were used to assess baseline variables that were likely predictors
of death during hospitalization. Unless stated otherwise, comparison tests
were two sided and a P-value <0.05 was considered statistically significant.
CD and pulmonary oedema 605
Table 1. Characteristics of the study population The median number of past medical events per patient was
3 (ranging from 0 to 8); the most frequent being hypertension
Variables Value (74%) and pulmonary oedema (36%), see Figure 2. The main
causes of ESRD were hypertension (36%), chronic glomer-
N 102
Men, n (%) 66 (65%)
ulonephritis (25%) and diabetes (18%). The initial clinical
Mean age, years (SD) 59.2 (15.7) and paraclinical presentation was dominated by the classical
Mean systolic blood pressure, mmHg (SD) 162.8 (44.8) features of pulmonary oedema (Table 1). Patients were on the
Mean diastolic blood pressure, mmHg (SD) 89.2 (24.4) following treatments prior to admission: calcium channel
Mean heart rate, beats/min (SD) 95 (23) blockers (42), angiotensin converting enzyme inhibitors
Mean respiratory rate, per min (SD) 29 (10)
Mean temperature, C (SD) 37.2 (1) (38), beta-blockers (37), diuretics (26), vasodilator (24), an-
Mean weight, kg (SD) 68.9 (17.7) giotensin II receptor antagonists (22), anti-platelets (20) and
Mean oxygen saturation, % (SD) 88 (9) anti-vitamin K anticoagulants (5). Four patients were on peri-
Mean Glasgow score (SD) 14 (2) toneal dialysis and 98 on intermittent conventional haemo-
Median APACHE II score, 28 (25–32)
(25th–75th percentiles)
dialysis. Overall, 75 (73.5%) were compliant with diet,
Median SOFA, (minimum–maximun) 6 (4–10) medication and dialysis; 9 (8.8%) had discontinued the med-
Mean serum potassium, mEq/L (SD) 5.09 (1.44) ication, while 16 (15.7%) had discontinued their dialysis prior
Median brain natriuretic peptide, (IQR) 3247 (2011– to admission.
4896.5) Pulmonary infections (26%), excessive interdialytic weight
Radiological findings
Cardiomegaly 53 (51%) gain (25%) and inappropriate dry weight prescription (23%)
Interstitial oedema 91 (87%) were the most frequent triggering factors associated with

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Alveolar oedema 68 (65%) pulmonary oedema. Cumulatively, however, the ultimate
Pleural effusion 15 (14%) cause of pulmonary oedema was of cardiac origin in 41%
Pulmonary condensation 23 (22%)
Electrocardiographic abnormalities
of the patients (Figure 3). A minority of patients (6.9%) were
Rhythm disorders 37 (36%) treated medically without dialysis. Conventional intermittent
Conduction disturbances 13 (13%) haemodialysis was the main technique used for dialysis in
Ischaemic signs, n (%) 28 (26%) the vast majority of patients (93, 1%). The vascular access
Echocardiographic variables was an arteriovenous fistula in 82 patients and a central cath-
Left ventricular ejection fraction, mean (SD) 53.7 (10.8)
Left ventricular hypertrophy 26/35 (74%) eter in 10 patients; three patients received peritoneal dialysis.
Left auricle dilation 27/56 (48%) Sixteen patients required mechanical ventilation after endo-
Hypertensive cardiomyopathy 32/57 (56%) tracheal intubation; 13 patients required non-invasive me-
Valvulopathy 10/57 (17%) chanical ventilation. The total duration of hospital stay was
Pericardial effusion 7/57 (12%)
<4 days in 60% of patients, while 8% stayed beyond 14 days.
APACHE II, Acute Physiology and Chronic Health Evaluation II; IQR, Forty-nine patients were discharged home versus 44 who
inter quartile range; SOFA, Sequential Failure Assessment score. were transferred to other medical services. Another nine
patients died in the hospital (four from cardiac causes and
three from sepsis). When compared with survivors, patients
who died were more likely to have been referred from an-
Results other hospital (89 versus 34%, P ¼ 0.002) and to have lower
systolic and diastolic blood pressure at admission (P  0.004
One hundred and twelve CD patients were admitted for APO for both). Furthermore, they had stayed longer in hospital
during the study period. Ten were excluded because of miss- (P ¼ 0.02) and required more frequently mechanical venti-
ing data. Therefore, a total of 102 patients were included in lation (Table 2). By logistic regression analysis, significant
the final analysis. Fifty-nine per cent of them came from predictors of death during hospitalization after adjustment
home, while 41% had been transferred from other hospital for sex and age were ‘being transferred from another hos-
units where onsite facilities for dialysis were not available. pital service’ [odds ratio 17.76, 95% CI ¼ (2.01–156.86),
The study population was dominated by males account- P ¼ 0.01], a need for mechanical ventilation [odds ratio
ing for 65%. The mean age was 59 years (range 20–88 21.65, 95% CI ¼ (3.92–119.57), P  0.001] and the Se-
years). Duration of dialysis ranged from 3 months to 10 quential Failure Assessment score [odds ratio 2.05 for every
years (mean duration: 2 years). The dialysis schedule prior additional point, 95% CI ¼ (1.16–3.64), P ¼ 0.01].
to hospitalization was the combination Monday, Wednes-
day and Friday for one-half of the patients and Tuesday,
Thursday and Saturday for the other half. The distribution Discussion
of patients according to their admission days was as fol-
lowed: 33 (32.5%) on Monday, 13 (12.7%) on Tuesday, Our study highlights the importance of pulmonary oedema
11(10.8%) on Wednesday, 6 (5.9%) on Thursday, 8 (7.8%) as a cause of intensive care admissions in CD patients, with
on Friday, 13 (12.7%) on Saturday and 18 (17.6%) as much as 10% mortality. It tends to occur in the early
on Sunday (Figure 1). Patients on the dialysis schedule years of chronic dialysis and predominantly affects men.
Monday, Wednesday and Friday were more likely to be Those affected are characterized by a rich past medical
admitted on a Sunday, while those on the schedule Tues- history, dominated by hypertension, past episodes of pul-
day, Thursday and Saturday were more likely to be admit- monary oedema and ischaemic heart disease. Initial clinical
ted on a Monday (P < 0.001; Figure 1). and paraclinical presentation is dominated by classical
606
Bronchopneumonia
Excessive interdialytic weight gain
Innapropriate dry weight prescription
Hypertensive crisis
Ischaemic heart disease
Dialysis discontinuation
Sepsis
Arythmia
Heart failure (unknown aetiology) 6
Others 3
Treatment discontinuation 3
Hyperhydration 1
0 5
Fig. 3. Aetiology of pulmonary oedema.
features of pulmonary oedema. Cardiovascular disorders
were the leading cause of pulmonary oedema in our study
population. However, extracellular volume expansion or
fluid overload secondary to poor compliance to diet and
inappropriate estimation of the dry weight, and chest in-
fections were also major causes for this condition. Infec-
tions and cardiovascular disease were the main causes of
death.
We are not aware of any similar study which could
provide comparative figures. Existing series of CD
patients in ICU have generally focused on causes of hos-
pitalizations and outcomes [3, 11, 12]. These studies,
however, have acknowledged the high prevalence of pul-
monary oedema among CD patients [3, 11, 12]. Our
study population was made up of more men, reflecting
the well-described male dominance among individuals
with chronic renal diseases [13]. A striking finding
was the pattern of admission day: patients on the
Monday-Wednesday-Friday maintenance dialysis sched-
ule were typically admitted on a Sunday, while those on
the Tuesday-Thursday-Saturday were typically admitted
on a Monday. Because these admission days are virtually
the days at which these patients would have received
their dialysis session in the absence of a Sunday gap,
we speculate that weekend gaps represent a key contrib-
utor to pulmonary oedema in our population. Recent
evidence suggests that ‘intensive dialysis’ (six sessions
per week) as opposed to conventional dialysis (three
sessions per week) does not affect hospitalization or
death unrelated to vascular access in the general popula-
tion of CD patients [14]. Our findings could thus merely
reflect a decreased tolerance to fluid overload in selected
patients with a poor heart condition and/or with poor
adherence to the common restrictions in salt and water
during the weekend.
M.-P. Halle et al.
27
26
24
18
11
8
8
8
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10 15 20 25 30
Frequency
Treatment and prognosis of pulmonary oedema depend
on its cause. As a result of the high cardiovascular risk
profile of individuals with CKD, cardiovascular disease
was an important cause of pulmonary oedema in our pop-
ulation [15-17]. Fluid and salt abuse have been reported as
the most common causes of pulmonary oedema in patients
on renal replacement therapy [20]. We also found a high
percentage of poor dietary compliance in our study. Over-
estimation of the dry weight and pulmonary infection
were also common causes in our patients. The estimation
of dry weight in patients on CD is a daunting task. It is
very often based on the occurrence of clinical signs attrib-
utable to extracellular volume contraction. The dry weight
should be reviewed often taking into account new clinical
events. An important finding was the number of patients
successfully treated medically, indicating that vasodilators,
nitrates and diuretics were still effective in CD patients.
The death rate in our study (9%) is similar to that reported
by studies of APO in patients with coronary diseases or heart
failure [6, 9, 18-20] and also in patients with APO in general
internal medicine [13] or in CKD patients in general in ICU
[11] This finding is striking and should be interpreted with
caution given the small size of our population. CVD and
infections have well been documented as leading causes of
death in CD patients [3, 15-17]. Interestingly, the cause of
pulmonary oedema was not a determinant of death in our
study. The association of hospital source with death is prob-
ably explained by the fact that patients often deteriorate
following inter-hospital transfers. Their underlying illnesses
were likely to be more severe. Mechanical invasive ventila-
tion is known as a predictor of death [11, 13, 19]. In our
study, the primary indication for mechanical ventilation in
many patients was not for pulmonary oedema, but instead
for pulmonary infection, a common cause of decompensa-
tion in this population.
 CD and pulmonary oedema 607
Table 2. Characteristics for those who survived and those who died identify the predictors of the outcome in this specific
during hospitalization population and to better tailor their management.
Variables Survivors Non-survivors P
Conflict of interest statement. None declared.
Number 93 9
Age (years) 59.7 6 15.7 53.7 6 15.9 0.27
Sex (men, n) 61 5 0.72
Average number 362 362 0.57 References
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