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Peritoneal Dialysis and Cough
Peritoneal Dialysis and Cough ACCP Evidence-Based Clinical Practice Guidelines Susan M. Tarlo, MBBS, FCCP
Objective: To review the clinical associations between peritoneal dialysis (PD) and cough. Methodology: A literature review was performed on PubMed for articles published between 1983 and 2004 using the search terms “dialysis” and “cough.” Results/conclusions: Patients receiving PD are more likely to develop a cough than other patients with end-stage renal disease who are receiving hemodialysis. Although both groups of patients frequently receive medications, such as angiotensin-converting enzyme inhibitors and -adrenergic blocking agents, that can trigger cough and both may be at increased risk for fluid overload and pulmonary edema, the increased risk associated with PD appears to relate to gastroesophageal reflux, likely from the peritoneal dialysate. (CHEST 2006; 129:202S–203S) Key words: cough; hemodialysis; peritoneal dialysis Abbreviations: ACE ⫽ angiotensin-converting enzyme; GERD ⫽ gastroesophageal reflux disease; PD ⫽ peritoneal dialysis
receiving peritoneal dialysis (PD) are at P atients increased risk of developing a chronic cough. A 1–3
literature review was performed using the search terms “dialysis” and “cough” on PubMed for articles published between 1983 and 2004. In one study,2 a persistent cough for at least 4 weeks was reported in 22% of PD patients and was significantly more frequent than among hemodialysis patients (7% in the same study). Many causes of cough would be expected to be more frequent in PD patients. Gastroesophageal reflux disease (GERD) may be initiated or exacerbated because there are increased intraperitoneal pressures during PD,4 and a history of heartburn was significantly more commonly reported by PD patients with cough (67%) compared to PD patients without cough (29%),2 although the use of GERD medications was not significantly different (80% vs 68%, respectively).2 Symptoms consistent with asthma (wheezing) were also significantly more frequent in PD patients with cough compared with PD patients without cough (40% vs 16%, Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Susan M. Tarlo, MBBS, FCCP, Toronto Western Hospital, EC4 – 009, 399 Bathurst St, Toronto, ON, M5T 2S8 Canada; e-mail [email protected] 202S
respectively), as was a self-reported “allergy history” (44% vs 16%, respectively; p ⫽ 0.04).2 Other potential causes of cough with increased prevalence in this population include the frequent use of medications that increase the risk of cough such as angiotensin-converting enzyme (ACE) inhibitors, which compete for ACE binding sites in the lungs, and -adrenergic blocking medications, which may exacerbate asthma by triggering bronchoconstriction. PD patients are also at increased risk of pulmonary edema as an additional cause of cough. In addition, as with other patients with immunosuppression, there is increased risk of infectious causes of cough such as tuberculosis.5 A rare reported cause of cough is the leakage of PD fluid into the mediastinum.6 Trials of therapy for dialysis patients with cough of different suspected causes would add further evidence for management recommendations in this group of patients. Summary of Recommendation 1. In patients receiving long-term peritoneal dialysis with cough evaluate the patient for the potential causes with increased prevalence in this population such as GERD, ACE inhibitors, pulmonary edema, asthma Diagnosis and Management of Cough: ACCP Guidelines
that may be exacerbated by -adrenergicblocking medications, and infection. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
3 4
5
References 1 Tarlo SM. Peritoneal dialysis and cough. Perit Dial Int 2003; 23:424 – 426 2 Min F, Tarlo SM, Bargman J, et al. Prevalence and causes of
www.chestjournal.org
6
cough in chronic dialysis patients: a comparison between hemodialysis and peritoneal dialysis patients. Adv Perit Dial 2000; 16:129 –133 Holley JL, Piraino B. CAPD-associated cough. Perit Dial Int 1995; 15:392–393 Twardowski ZJ, Khanna R, Nolph KD, et al. Intraabdominal pressures during natural activities in patients treated with continuous ambulatory peritoneal dialysis. Nephron 1986; 44:129 –135 Ekim M, Tumer N, Bakkaloglu S. Tuberculosis in children undergoing continuous ambulatory peritoneal dialysis. Pediatr Nephrol 1999; 13:577–579 Kim YL, Cho YJ, Park SH, et al. Peritoneal-mediastinal leakage complication of peritoneal dialysis. Am J Kidney Dis 2003; 42:E17–E19
CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT
203S
Objective: To review the clinical associations between peritoneal dialysis (PD) and cough. Methodology: A literature review was performed on PubMed for articles published between 1983 and 2004 using the search terms “dialysis” and “cough.” Results/conclusions: Patients receiving PD are more likely to develop a cough than other patients with end-stage renal disease who are receiving hemodialysis. Although both groups of patients frequently receive medications, such as angiotensin-converting enzyme inhibitors and -adrenergic blocking agents, that can trigger cough and both may be at increased risk for fluid overload and pulmonary edema, the increased risk associated with PD appears to relate to gastroesophageal reflux, likely from the peritoneal dialysate. (CHEST 2006; 129:202S–203S) Key words: cough; hemodialysis; peritoneal dialysis Abbreviations: ACE ⫽ angiotensin-converting enzyme; GERD ⫽ gastroesophageal reflux disease; PD ⫽ peritoneal dialysis
receiving peritoneal dialysis (PD) are at P atients increased risk of developing a chronic cough. A 1–3
literature review was performed using the search terms “dialysis” and “cough” on PubMed for articles published between 1983 and 2004. In one study,2 a persistent cough for at least 4 weeks was reported in 22% of PD patients and was significantly more frequent than among hemodialysis patients (7% in the same study). Many causes of cough would be expected to be more frequent in PD patients. Gastroesophageal reflux disease (GERD) may be initiated or exacerbated because there are increased intraperitoneal pressures during PD,4 and a history of heartburn was significantly more commonly reported by PD patients with cough (67%) compared to PD patients without cough (29%),2 although the use of GERD medications was not significantly different (80% vs 68%, respectively).2 Symptoms consistent with asthma (wheezing) were also significantly more frequent in PD patients with cough compared with PD patients without cough (40% vs 16%, Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal. org/misc/reprints.shtml). Correspondence to: Susan M. Tarlo, MBBS, FCCP, Toronto Western Hospital, EC4 – 009, 399 Bathurst St, Toronto, ON, M5T 2S8 Canada; e-mail [email protected] 202S
respectively), as was a self-reported “allergy history” (44% vs 16%, respectively; p ⫽ 0.04).2 Other potential causes of cough with increased prevalence in this population include the frequent use of medications that increase the risk of cough such as angiotensin-converting enzyme (ACE) inhibitors, which compete for ACE binding sites in the lungs, and -adrenergic blocking medications, which may exacerbate asthma by triggering bronchoconstriction. PD patients are also at increased risk of pulmonary edema as an additional cause of cough. In addition, as with other patients with immunosuppression, there is increased risk of infectious causes of cough such as tuberculosis.5 A rare reported cause of cough is the leakage of PD fluid into the mediastinum.6 Trials of therapy for dialysis patients with cough of different suspected causes would add further evidence for management recommendations in this group of patients. Summary of Recommendation 1. In patients receiving long-term peritoneal dialysis with cough evaluate the patient for the potential causes with increased prevalence in this population such as GERD, ACE inhibitors, pulmonary edema, asthma Diagnosis and Management of Cough: ACCP Guidelines
that may be exacerbated by -adrenergicblocking medications, and infection. Level of evidence, expert opinion; benefit, substantial; grade of recommendation, E/A
3 4
5
References 1 Tarlo SM. Peritoneal dialysis and cough. Perit Dial Int 2003; 23:424 – 426 2 Min F, Tarlo SM, Bargman J, et al. Prevalence and causes of
www.chestjournal.org
6
cough in chronic dialysis patients: a comparison between hemodialysis and peritoneal dialysis patients. Adv Perit Dial 2000; 16:129 –133 Holley JL, Piraino B. CAPD-associated cough. Perit Dial Int 1995; 15:392–393 Twardowski ZJ, Khanna R, Nolph KD, et al. Intraabdominal pressures during natural activities in patients treated with continuous ambulatory peritoneal dialysis. Nephron 1986; 44:129 –135 Ekim M, Tumer N, Bakkaloglu S. Tuberculosis in children undergoing continuous ambulatory peritoneal dialysis. Pediatr Nephrol 1999; 13:577–579 Kim YL, Cho YJ, Park SH, et al. Peritoneal-mediastinal leakage complication of peritoneal dialysis. Am J Kidney Dis 2003; 42:E17–E19
CHEST / 129 / 1 / JANUARY, 2006 SUPPLEMENT
203S