Diagnosis and Management of Pulmonary Hypertension in Patients With CKD

Abstract

Pulmonary hypertension (PH) is a highly prevalent and important condition in adults with chronic kidney disease (CKD). In this review, we summarize the definition of PH, discuss its pathophysiology and classifications, and describe diagnostic and management strategies in patients with CKD, including those with kidney failure treated by kidney replacement therapy. In the general population, PH is classified into 5 groups based on clinical presentation, pathology, hemodynamics, and management strategies. In this classification system, PH in CKD is placed in a diverse group with unclear or multifactorial mechanisms, although underlying cardiovascular disease may account for most cases. CKD may itself directly incite pulmonary circulatory dysfunction and remodeling through uremic toxins, inflammation, endothelial dysfunction, and altered vasoregulation. Despite several studies describing the higher prevalence of PH in CKD and kidney failure, along with an association with poor outcomes, high-quality evidence is not available for its diagnostic and management strategies in those with CKD. In CKD not requiring kidney replacement therapy, volume management along with treatment of underlying risk factors for PH are critical. In those receiving hemodialysis, options are limited and transition to peritoneal dialysis may be considered if recurrent hypotension precludes optimal volume control.

Keywords: Chronic kidney disease (CKD); death; dialysis; end-stage renal disease (ESRD); heart failure; kidney failure; mean pulmonary arterial pressure (PAPm); pulmonary arterial hypertension (PAH); pulmonary circulatory dysfunction; pulmonary hypertension (PH); review; vascular remodeling; volume management.

Figure 1.. Suggested algorithm for PH identification and management in persons with non-dialysis or dialysis-dependent CKD.

References: ¹Galiè et al. ²Vachiery et al. Abbreviations: PH pulmonary hypertension; SLE, systemic lupus erythematosus; SS systemic sclerosis; HD hemodialysis; TRV tricuspid regurgitant velocity; RHC right heart catheterization; HTN hypertension; AF atrial fibrillation; LA left atrium; HRCT high resolution CT; PFTs pulmonary function tests; PAH pulmonary arterial hypertension; CTEPH chronic thromboembolic PH; AV access arteriovenous HD access