What can cause pulmonary edema

Hyperglycemia caused pulmonary edema in a hemodialysis patient

A.S.EL-Hennawy, A.K. Mahmood (Dialysis & Transplantation, Vol 34, Num 9, Sept 2005, www.eneph.com)

The patient, a woman of 53 years, with ESRD due todiabetes mellitus and hypertension, complained of shortness of breath, which arose the day after the hemodialysis session. Pain in the chest, palpitations, fever, cough and sputum are absent. The patient reported that about a week ago she had independently stopped injections of insulin, she did not take any oral hypoglycemic drugs.

The patient has a marked respiratory distress, a BP of 180/80 mm Hg, a pulse of 120 beats / min, a BHD of 28 / min. Objectively, swelling of the jugular veins is noted, with auscultation of the lungs - wet rales.

X-ray examination revealedcardiomegaly, pulmonary edema (interstitial edema, bilateral peripheral alveolar edema, and a small bilateral accumulation of pleural fluid). With ECG - sinus tachycardia and signs of left ventricular hypertrophy.

Primary laboratory blood test data

Sodium (in plasma) 116 mEq / L
Potassium 4.0 mEq / L
Chlorine 79
CO2 18.9
Glucose 1135 mg / dL
Urea 49 mg / dL
Plasma creatinine 6.5 mg / dL
Plasma osmolality 315 mOsm / kg water
Creatinine phosphokinase 120 IU / L
Troponin-I <0.1 ng / ml

Treatment
The patient was assigned IV insulin infusion, andAfter 24 hours, her condition improved significantly. The level of glucose in the blood was 220 mg / dL, the concentration of sodium in the plasma - 133 mEq / L. When repeated X-ray examination, performed the day after admission, signs of pulmonary edema were not detected.

Discussion
With hyperglycemia in patients with ESRD maydevelop hyponatremia with increased osmolarity of the plasma. An increase in the concentration of glucose in the blood, and the associated increase in osmolality, causes the fluid to move from the cells to the bloodstream, reducing the level of sodium in the blood due to hemodilution. The widely used correction value - a decrease in the sodium concentration by 1.6 mEq / L for every 100 mg / dl of glucose level increase was obtained experimentally. In practice, these figures may be larger, and a correction value of 2.4 mEq / L for every 100 mg / dl of glucose more accurately reflects the actual processes.

When the osmolarity of the plasma increases, the liquidbegins to move from intra-to extracellular space. In patients with normal renal function, hyperglycemia leads to osmotic diuresis and a decrease in the volume of circulating blood. With ESRD, severe hyperglycemia can lead to the accumulation of estracellular fluid, as a consequence, pulmonary edema.