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      Breathlessness worsened by haemodialysis

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          Abstract

          A 54 year old lady with underlying chronic lung disease on long term oxygen therapy and end stage renal disease of unknown aetiology on regular haemodialysis for two years started developing progressive shortness of breath during her routine haemodialysis. She was unable to tolerate her haemodialysis sessions which had to be terminated prematurely in view of her symptoms despite adjustment of her dry weight and treatment of anaemia. She was not in chronic fluid overload and her symptoms always worsened after initiation of haemodialysis and improved after termination of haemodialysis. She was admitted to hospital for further investigations and initially treated for a lung infection but her symptoms did not improve. A computed tomography pulmonary angiography did not reveal any evidence of pulmonary embolism, and was consistent with chronic fibrotic changes. Her hypoxemia was concluded to be due to her underlying chronic lung disease, worsened by alveolar hypoventilation during haemodialysis. Her symptoms improved slightly with supplemental oxygen during her routine haemodialysis but we had to shorten her haemodialysis duration to 3 hours.

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          Most cited references13

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          Intradialytic Hypoxemia and Clinical Outcomes in Patients on Hemodialysis.

          Intradialytic hypoxemia has been recognized for decades, but its associations with outcomes have not yet been assessed in a large patient cohort.
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            Intradialytic Hypoxemia in Chronic Hemodialysis Patients

            When kidney failure occurs, patients are at risk for fluid overload states, which can cause pulmonary edema, pleural effusions, and upper airway obstruction. Kidney disease is also associated with impaired respiratory function, as in central sleep apnea or chronic obstructive pulmonary disease. Hence, respiratory and renal diseases are frequently coexisting. Hypoxemia is the terminal pathway of a multitude of respiratory pathologies. The measurement of oxygen saturation (SO 2 ) is a basic and commonly used tool in clinical practice. Both arterial oxygen saturation (SaO 2 ) and central venous oxygen saturation (ScvO 2 ) can be easily obtained in hemodialysis (HD) patients, SaO 2 from an arteriovenous access and ScvO 2 from a central catheter. Here, we give a brief overview of the anatomy and physiology of the respiratory system, and the different technologies that are currently available to measure oxygen status in dialysis patients. We then focus on literature regarding intradialytic SaO 2 and ScvO 2 . Lastly, we present clinical vignettes of intradialytic drops in SaO 2 and ScvO 2 in association with different symptoms and clinical scenarios with an emphasis on the pathophysiology of these cases. Given the fact that in the general population hypoxemia is associated with adverse outcomes, including increased mortality, cardiac arrhythmias and cardiovascular events, we posit that intradialytic SO 2 may serve as a potential marker to identify HD patients at increased risk for morbidity and mortality.
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              Impact of Hemodialysis on Dyspnea and Lung Function in End Stage Kidney Disease Patients

              Background. Respiratory symptoms are usually underestimated in patients with chronic kidney disease undergoing maintenance hemodialysis. Therefore, we set out to investigate the prevalence of patients chronic dyspnea and the relationship of the symptom to lung function indices. Methods. Twenty-five clinically stable hemodialysis patients were included. The mMRC dyspnea scale was applied before and after hemodialysis. Spirometry, single breath nitrogen test, arterial blood gases, static maximum inspiratory (P imax⁡) and expiratory (P emax⁡) muscle pressures, and mouth occlusion pressure (P 0.1) were also measured. Results. Despite normal spirometry, all patients (100%) reported mild to moderate degree of chronic dyspnea pre which was reduced after hemodialysis. The sole predictor of (Δ) mMRC was the (Δ) P 0.1 (r = 0.71, P < 0.001). The P imax⁡ was reduced before and correlated with the duration of hemodialysis (r = 0.614, P < 0.001), whilst after the session it was significantly increased (P < 0.001). Finally (Δ) weight was correlated with the (Δ) P imax⁡  %pred (r = 0.533, P = 0,006) and with the (Δ) CV (%pred) (r = 0.65, P < 0.001). Conclusion. We conclude that dyspnea is the major symptom among the CKD patients that improves after hemodialysis. The neuromechanical dissociation observed probably is one of the major pathophysiologic mechanisms of dyspnea.
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                Author and article information

                Contributors
                Journal
                Respir Med Case Rep
                Respir Med Case Rep
                Respiratory Medicine Case Reports
                Elsevier
                2213-0071
                01 November 2018
                2019
                01 November 2018
                : 26
                : 6-8
                Affiliations
                [1]Department of Medicine, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
                Author notes
                []Corresponding author. rizna_c@ 123456hotmail.com
                Article
                S2213-0071(18)30289-2
                10.1016/j.rmcr.2018.10.022
                6216102
                30416956
                7ff96d2a-323e-46cc-835f-b1e03cd00c43
                © 2018 The Authors. Published by Elsevier Ltd.

                This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                : 14 September 2018
                : 23 October 2018
                : 23 October 2018
                Categories
                Case Report

                chronic lung disease,end stage renal disease,haemodialysis,hypoxemia,hypoventilation

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