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Hemoptysis in Patients With Renal Insufficiency^*

The Role of Flexible Bronchoscopy

^* From the Department of Internal Medicine (Drs. Kallay, Dunagan, Adair, and Chin), Section on Pulmonary and Critical Care, Wake Forest University Baptist Medical Center, Winston-Salem, NC; and the Division of Pulmonary and Critical Care Medicine (Dr. Haponik), Johns Hopkins University School of Medicine, Baltimore, MD.

Correspondence to: Nicholas Kallay, MD, Pulmonary Fellow, Section on Pulmonary and Critical Care Medicine, Wake Forest University Baptist Medical Center, Medical Center Blvd, Winston-Salem, NC 27157-1054; e-mail: nkallay{at}wfubmc.edu

Study objectives: To assess the indications, yield, and therapeutic impact of flexible bronchoscopy (FB) in patients with hemoptysis and renal insufficiency.

Design: Retrospective cohort analysis.

Setting: Tertiary-care university hospital.

Patients: Thirty-four patients over a 7.5-year period who underwent FB to evaluate hemoptysis in the setting of renal insufficiency (ie, serum creatinine level, > 1.5 mg/dL).

Measurements and results: The etiology of hemoptysis was undetermined in 41% of cases. Defined causes of bleeding included infections (29%), pulmonary renal syndromes (15%), airway injury (9%), and pulmonary embolism (6%). No specific bleeding site was identified, but FB lateralized hemorrhaging to one lung in 24% of patients. FB results influenced therapy in 29% of patients overall and in 8% of patients without respiratory tract infection. The hospital survival rate was 47% and did not differ based on the presence or absence (presence vs absence) of the following variables: a defined etiology for hemoptysis (45% vs 50%); lateralized bleeding (38% vs 50%); or management alterations prompted by other FB findings (50% vs 46%). Factors associated with survival included the onset of bleeding prior to hospital admission (80% vs 33%; p = 0.02), the absence of respiratory failure requiring mechanical ventilation at the time of FB (90% vs 29%; p = 0.002), and lack of prohemorrhagic factors (other than uremia) such as disseminated intravascular coagulation, recent treatment with warfarin, heparin, or antiplatelet agents (78% vs 33%; p = 0.05). During the 6 months following hospital discharge, hemoptysis recurred in 14% of patients, and 5 patients died, for an overall mortality rate of 62%.

Conclusions: These data suggest that FB in hospitalized patients with hemoptysis and renal insufficiency, and without radiographic findings suggesting neoplastic disease, has a low yield and limited impact. Whether FB influences outcome in selected patients in this setting requires prospective investigation.

Key Words: bronchoscopy • hemoptysis • human • kidney failure • outcome assessment