Pulmonary Congestion Predicts Cardiac Events and Mortality in ESRD

Abstract

Pulmonary congestion is highly prevalent and often asymptomatic among patients with ESRD treated with hemodialysis, but whether its presence predicts clinical outcomes is unknown. Here, we tested the prognostic value of extravascular lung water measured by a simple, well validated ultrasound B-lines score (BL-US) in a multicenter study that enrolled 392 hemodialysis patients. We detected moderate-to-severe lung congestion in 45% and very severe congestion in 14% of the patients. Among those patients with moderate-to-severe lung congestion, 71% were asymptomatic or presented slight symptoms of heart failure. Compared with those patients having mild or no congestion, patients with very severe congestion had a 4.2-fold risk of death (HR=4.20, 95% CI=2.45-7.23) and a 3.2-fold risk of cardiac events (HR=3.20, 95% CI=1.75-5.88) adjusted for NYHA class and other risk factors. Including the degree of pulmonary congestion in the model significantly improved the risk reclassification for cardiac events by 10% (P,0.015). In summary, lung ultrasound can detect asymptomatic pulmonary congestion in hemodialysis patients, and the resulting BL-US score is a strong, independent predictor of death and cardiac events in this population.

Variables associated with lung congestion as assessed by chest ultrasound in diabetics undergoing hemodialysis

“…It is estimated that 60% of patients on maintenance HD present lung congestion. 1 Besides hypervolemia and heart failure, high level of inflammation in ESRD patients contributes to lung congestion due to microvascular lung disease, provoking capillary leakage. 2,3 Lung congestion is a strong prognostic marker of cardiac events and death among ESRD patients submitted to HD.…”

“…HD patients with severe congestion have a 4.2-fold higher risk of death and a 3.2-fold higher risk of cardiac events, like myocardial infarction, angina, heart failure and arrhythmia. 1 Clinical evaluation and bioimpedance analysis are daily tools in dialysis centers to estimate overhydration among HD patients in order to control lung congestion. However, extracellular volemia as assessed by bioimpedance is very weakly associated with lung water.…”

“…1 Secondly, lung water is estimated by assessing volume overload by bioimpedance. But, as stated above, total extracellular water may be not correlated with lung water.…”

Lung ultrasound: a new basic, easy, multifunction imaging diagnostic tool in children undergoing pediatric cardiac surgery

“…Data on prognostic utility of LUS in children are very limited. In adults instead (5) the prognostic value of lung water has been proved in different setting including heart failure (16), acute coronary syndrome (17,18) and dialysis (19). Furthermore the persistence of pulmonary congestion predicts re-hospitalization in heart failure (20,21).…”

Transthoracic pulmonary ultrasonography: looking inside the lungs to better treat the dialysis patient

“…For example, Zoccali et al 6 found that the risks of death and cardiovascular events were 4.2-and 3.2-fold higher, respectively, in patients undergoing hemodialysis who had severe pulmonary congestion identified through B-lines compared with patients with mild to moderate accumulation of lung interstitial water.…”