Respiratory complications in chronic kidney disease: Evidence on prevention, assessment, and management, with an emphasis on advanced disease and hemodialysis

Abstract

Introduction: Chronic kidney disease (CKD) presents systemic repercussions that can compromise the respiratory system, particularly in patients with advanced disease or those undergoing hemodialysis. Key alterations include respiratory muscle weakness, impaired pulmonary function and functional capacity, pulmonary congestion associated with fluid overload, pulmonary hypertension, and increased susceptibility to respiratory infections. The diversity of these manifestations highlights the importance of synthesizing evidence regarding their characterization, prevention, assessment, and management. Objective: To critically synthesize scientific evidence on respiratory complications and alterations associated with CKD, as well as strategies investigated for their prevention, assessment, and management, considering the prevalence of studies involving patients with advanced disease or those undergoing hemodialysis. Methods: This is an integrative literature review of a qualitative and descriptive nature, with searches conducted on September 20, 2026, in the PubMed/MEDLINE, SciELO, and Virtual Health Library (VHL) databases. Studies published between 2020 and 2026 in Portuguese or English, with full text available free of charge, were considered. The search strategies employed MeSH/DeCS descriptors and free-text terms organized into three conceptual axes: CKD and hemodialysis; respiratory complications and alterations; and prevention, assessment, and management strategies. Two complementary searches were performed, combining the first axis separately with the others using the Boolean operators AND and OR. A total of 74 records were identified, 24 of which were duplicates. After screening 50 publications and evaluating 30 full-text articles, nine studies were included: three randomized clinical trials and six systematic reviews. The synthesis was descriptive and qualitative, without a formal, standardized assessment of methodological quality or risk of bias. Results: The evidence identified various respiratory and functional consequences associated with CKD, including alterations in respiratory muscle strength, pulmonary function, functional capacity, pulmonary congestion, and pulmonary hypertension, as well as an increased risk of mortality in patients with respiratory infections. A meta-analysis identified a pooled prevalence of pulmonary hypertension of approximately 38% in patients with CKD and 42% among individuals with end-stage renal disease undergoing hemodialysis. Regarding interventions, respiratory muscle training yielded the most consistent results concerning inspiratory and expiratory muscle strength, whereas effects on functional capacity, pulmonary function, and quality of life varied across studies. Influenza and COVID-19 vaccination were investigated primarily through immunological outcomes—showing lower seroconversion and seroprotection rates in hemodialysis patients—without allowing for a direct determination of the magnitude of protection against infection, hospitalization, or mortality. Lung ultrasound was associated with the identification and monitoring of congestion and fluid overload, although its benefits regarding long-term clinical outcomes remain insufficiently demonstrated. The predominance of secondary evidence, methodological heterogeneity, and potential overlap between studies limited the interpretation of result consistency. Conclusion: Available evidence allows for the characterization of various respiratory complications associated with CKD, particularly in patients with advanced disease or those undergoing hemodialysis. Respiratory muscle training demonstrated benefits for muscle strength, whereas the effects of other interventions on clinical and functional outcomes remain less consistent. Vaccination was investigated mainly regarding immunological response, and lung ultrasound proved useful for assessing congestion, though there is no uniform evidence of long-term clinical benefits. The absence of a formal assessment of risk of bias, potential overlap of evidence, language and free-access restrictions, and study heterogeneity limit confidence in and the generalizability of the conclusions. Methodologically robust investigations are needed, featuring standardized outcomes and longitudinal follow-up, and covering different stages of CKD.