60 year old man with shortness of breath since 3 months

 A 60 yr old man ,daily laborer, resident of nakrekal ,came with chief complaints of shortness of breath since 3 months

History of presenting illness

Patient was apparently asymptomatic 4 years back .He used to go to work in the fields in the day and had one litter of toddy every day after work.

4yrs back- pt had frequent episodes of giddiness ,1-2 episodes, every 2-3 days, each episode lasting for around 5-10 minutes, not associated with nausea,vomiting,tinnitus, and relieved spontaneously on rest.

Pt went to a local hospital after one month, where he was diagnosed to have hypertension and started on medication.

He was asymptomatic for 1 year ,continued his daily field work, then he noticed having swelling of both lower limbs,which was insidious in onset and gradually progressive, upto knee, painless and pitting type, associated with generalized weakness. Went to  hospital after one month and found out to have kidney failure requiring dialysis.

In 2019,pt visited our hospital and was put on  conservative management for 1wk,following which hemodialysis through central venous catheter was initiated and continued with a frequency of dialysis once in 4-5 days without any significant complications. He underwent Av fistula surgery one month after starting dialysis .

He stopped going to work since the initiation of hemodialysis and stays at home ,and also stopped consuming toddy.

8 months back - pt started having swelling of left upper limb, Insidious onset gradually progressive ,which was initially reduced in size with limb elevation ,but later no improvement and not associated with fever ,local rise of temperature ,tenderness or ulceration. 

Since January 2022, pt is c/o shortness of breath ,grade 3 to 4 according to NYHA classification, associated with back pain and chest pain-diffuse ,dragging type ,aggravated on walking and relieved on rest and medication. Associated with left pleural effusion,transudative , around 1 litter of pleural fluid removed and symptoms subsided for few days. 2d echo revealed global hypokinesia with dilated chambers and dilated ivc with EF 28%.

Bowel habits regular,oliguria with decreased appetite and disturbed sleep

Time line of events

Till 2018

• Apparently asymptomatic 
• Worked as daily wage labour
• Occasional smoker
• Toddy drinker 1 ltr daily

2018

• Giddiness for 1 month
• Diagnosed as hypertension 
• Started on medication

2019

• Bilateral pedal edema
• Generalized weakness 
• Diagnosed as renal failure
• Started on hemodialysis 
• Av fistula for lt upper arm

2021

• Edema of left upper limb 
• Gradually progressed till left shoulder

2022

• Shortness of breath grade 3 -4
• Back pain 
• Associated with chest pain ,orthopnea
• HFrEF
• pleural effusion
• Pedal edema,facial puffiness,edema of both upper limbs 
• 
  

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General examination 

Pt is conscious, coherent, oriented to time ,place and person

Pallor +

Edema + in b/l upper limbs extending upto elbow in rt limb and upto shoulder on lt side

B/l lower limb edema upto knee, associated with facial puffiness. 

Lt axillary lymphnodes palpaple

Thrill over fistula site +

Vitals 

Temp -afebrile

Pulse rate - 90 /min

Resp rate - 20 cpm

Bp - 130 /90 mmhg

Spo2 98 % @ 4 lit 02

Systemic examination 

Cvs - dilated veins over the infra clavicular area and sternum +

s1 ,s2 heard 

JVP raised

Apex beat -left  6th intercoastal space,diffuse lateral to mid clavicular line

Respiratory system-

Decreased chest movements on left side 

Decreased breath sounds in left infraclavicular, mammary,axillary ,infra axillary and infra scapular areas

Per abdomen -soft ,non tender

Bowel sounds heard

Cns- no abnormality detected

no focal neurological deficits

ABG 

pH 7.4----7.38

pCo2 33.6----41.1

pO2 66.3----86.8

Hco3 20.5----23.8

O2 sat 93.6%----95.5

Hb- 8.6---7.7

Tlc 5,500----4500

Plt 2.0----1.8

RFT

Urea 97----50

Cr 5.6----3.2

Uric acid 4.6----3.2

Ca 9.2----9.4

Po4 2.5----2.4

Na 138----140

K 4.0----3.6

Cl 98----98

LFT

TB 0.7

DB 0.1

AST 15

ALT 12

ALP 252

TP 4.8

ALB 2.2

CUE 

ALB 1+

sugars nil 

PC 2-3

Sr ldh/pleural ldh - 109/240 -0.45

Sr protein/pleural protein -0.37

Diagnosis

Chronic renal failure with 

Heart failure with reduced ejection fraction 

Left sided pleural effusion 

Hypertension since 4 years

Treatment 

Tab nicardia 10 mg po tid

Tab lasix 40 mg po bd

Tab isolazine 50 mg 1/2 tab po bd

Tab orofer xt po od

Tab Ultracet 1/2 tab po qid

Hemodialysis thrice weekly

http://jyothsna113.blogspot.com/2022/01/58year-old-male-with-ckd-on-mhd.html

Discussion

https://onlinelibrary.wiley.com/doi/full/10.7863/ultra.15.14.11063

Venous Causes of Acute Arm Swelling:

-Venous Thrombosis and Stenosis

Studies have reported that up to 10% of patients with superficial vein  thrombosis may develop deep vein thrombosis, pulmonary embolism, or progression of superficial vein thrombus in 3 months.

Deep and central vein stenosis is also an important cause of arm swelling because if left untreated, it can result in graft dysfunction and failure.

-Draining Veins

 Large draining veins can also result in substantial arm swelling and may contribute to up to 40% of arteriovenous fistula failures. It is hypothesized that increased venous pressures promote filling of multiple collateral perforator veins, which can cause arm swelling and steal blood away from the fistula or graft. Central vein stenosis is often the inciting event; therefore, management usually involves treating the central vein stenosis in addition to coil embolization of the draining veins.

https://reader.elsevier.com/reader/sd/pii/S0741521408014328?token=3C2E3BC01E424D07A4C56BE57AE1A483CF8139921AE9E6018F2037E784F2B18EEE937917C946A9683EDD5D85F054F2BF&originRegion=eu-west-1&originCreation=20220322204106

A rare complication characterized by symptoms indistinguishable from cardiac failure. Because cardiac failure is very common in the dialysis-dependent population, differentiation is difficult. 

● Essentially a complication of autogenous AV access.

● Attempts to correlate AV access flow with cardiac

output have suggested an AV access flow
3 L/min or

an AV access flow that is
30% of the cardiac output is consistent with the diagnosis.

● A decrease in cardiac output after transient occlusion of the AV access is suggestive of the diagnosis.

● Management options

X Ligation—solves the problem if due to AV access

overload, but requires sacrifice of the access

X Flow restriction Banding—is a more attractive op-

tion in the setting of large AV access and AV access

flows.