Dyspnoea in CKD can be due to renal and/or non-renal causes. Common aetiologies include:
- Renal: Anaemia, Fluid overload
– Chronic lung disease eg COPD, pulmonary fibrosis
– Cardiac eg primary congestive cardiac failure, diastolic dysfunction, and unstable angina
– General deconditioning
Correct underlying aetiology if possible. Treat co-morbid anxiety. Non-pharmacological measures are the mainstay of treatment.
- Check iron, B12, folate and replace as required. For iron replete patients, consider EPO if Hb <100g/L. For non-dialysis patients with Hb<100g/L, treat anaemia to symptoms rather than biochemical targets.
- Fluid overload. May be both renal and cardiac causes
– Restrictions to sodium and water intake
– Loop diuretics (frusemide or bumetanide): may require higher doses to achieve diuretic effect. Will need electrolyte monitoring.
– Consider intravenous diuretics in resistant cases, as gastrointestinal oedema may affect oral drug absorption.
- Hand held fan.
- Gentle physical exercise to improve conditioning.
- Energy conservation strategies.
Oxygen therapy has not been shown to be better than placebo in patients with normal oxygen saturation.
Consider palliative oxygen in hypoxic patients.
Opioids are first-line treatment. Hydromorphone: start with 0.25mg-0.5mg po tds, and up-titrate by 0.25mg to effect (max 4mg over 24 hours)
Benzodiazepines can be added to opioids.
– Lorazepam 0.5mg sublingually bd to tds. Uptitrate by 0.5mg to 1mg tds.
– In acute cases, midazolam 2.5-5mg subcut can be used in addition to opioids