1Dunedin Public Hospital, New Zealand, Dunedin, New Zealand
Background: Intradialytic pulmonary oedema is associated with hypotension and hypoxaemia and leads to difficult to manage haemodialysis sessions. We believe this is the first reported case where Swan Ganz catheter measurements were undertaken during dialysis to evaluate this phenomenon.
Case report: A 71 year old woman presented with dysponea and progressive kidney injury requiring dialysis. Four months prior she underwent an open AAA repair complicated by intraoperative hypotension requiring a single haemodialysis session. Echocardiogram showed moderate mitral stenosis, Atrial Fibrillation with preserved ejection fraction.She was commenced on dialysis with rate control for resistant tachycardia. Severe acute pulmonary oedema developed soon after the commencement of each dialysis session with hypoxia and hypotension. A coronary angiogram revealed LAD and RCA lesions treated with PCI. Unfortunately intradialytic pulmonary oedema continued. Right heart catheterization with continuous measurements of right and left sided pressures was then performed during dialysis. This showed diastolic dysfunction with pulmonary capillary wedge pressure 29mmHg (<12) prior to commencing dialysis. Thirty minutes into dialysis there was an acute elevation in the pulmonary arterial pressure (from 35 to 58mmHg) and pulmonary capillary wedge pressures increased to 48mmHg. The impression was this signified severe diastolic dysfunction with moderate mitral stenosis – not amenable for operative intervention.Due to these events the decision was made to cease further attempts at haemodialysis and a PD catheter was inserted.
Conclusions: Mitral stenosis with severe diastolic dysfunction triggered rapid elevations in left and right sided heart pressures during dialysis led to recurrent severe intradialytic pulmonary oedema which rendered ongoing haemodialysis impossible.
I am first year nephrology advance trainee at Dunedin Hospital. I graduated from Mumbai, India before moving to Dunedin 5 years ago. Before taking up full time clinical role, I worked as a Teaching fellow at Medical schools both in Otago and Auckland. I have a huge interest in Transplant medicine and would like to pursue in career in the same.