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Pulmonary hypertension in hemodialysis patients

Authors
William Hopkins, MD
Thomas A Golper, MD
Gerald A Beathard, MD, PhD
Section Editors
Jeffrey S Berns, MD
David L Cull, MD
Deputy Editors
Alice M Sheridan, MD
Kathryn A Collins, MD, PhD, FACS
Geraldine Finlay, MD

INTRODUCTION

Dialysis patients, particularly those on hemodialysis, are at risk for development of or worsening of pre-existing pulmonary hypertension (PH). Although multifactorial, the increased risk is due, in part, to the presence of an arteriovenous (AV) access.

PH among dialysis patents is presented in this topic review. The evaluation and management of AV fistula-associated heart failure and other complications of hemodialysis AV access are presented separately. (See "Evaluation and management of heart failure caused by hemodialysis arteriovenous access" and "Arteriovenous fistula creation for hemodialysis and its complications", section on 'Complications of AV fistula placement' and "Arteriovenous graft creation for hemodialysis and its complications", section on 'Complications of AV graft placement'.)

DEFINITION AND CLASSIFICATION

PH is defined as an elevated mean arterial pressure ≥25 mmHg at rest [1]. PH is classified into the five groups given in the table (table 1) [1,2]. Patients with end-stage renal disease (ESRD) are considered to have group 5 PH, which refers to PH of unclear or multifactorial mechanism (table 1) [1]. However, some ESRD patients may also have PH from heart failure (group 2) or chronic lung disease (group 3). (See "Classification and prognosis of pulmonary hypertension in adults".)

EPIDEMIOLOGY AND RISK FACTORS

The reported prevalence of PH among dialysis patients has ranged from less than 10 percent to over 50 percent [3-16]. The wide range primarily relates to the technique used to diagnose PH (echo/Doppler versus catheterization), the variability in diagnostic criteria, and the presence or absence of symptoms [15]. In the only study in which the PH diagnosis was based on right-sided cardiac catheterization (the gold standard), all patients were selected for study based upon presence of unexplained dyspnea [16]. In this study, PH was present in 81 percent of hemodialysis patients and in 77 percent of nondialysis chronic kidney disease (CKD) patients. The mean pulmonary arterial pressure was higher in the patients on dialysis compared with the patients who were not on dialysis (42 versus 35 mmHg).

The risk appears to be higher among hemodialysis compared with peritoneal dialysis patients. In the four studies that directly compared hemodialysis patients with peritoneal dialysis patients, PH was higher in hemodialysis patients (19 to 59 percent versus <19 percent) [6,12-14].

               
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Literature review current through: Nov 2017. | This topic last updated: Sep 25, 2017.
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