Beyond Heart Failure: Diaphragmatic Dysfunction and Hypovolemia Misdiagnosed as Dialysis Intolerance

Introduction: Orthopnea in heart failure is typically linked to pulmonary congestion but can also result from less recognized causes such as diaphragmatic paralysis. In patients with overlapping advanced heart failure and CKD, symptoms may be misattributed, leading to inappropriate treatment. This case highlights how a multidisciplinary reassessment identified reversible causes of hypotension and dyspnea in a patient previously referred to hospice. Case Description: A 53-year-old woman with long QT syndrome, advanced heart failure, and CKD presented after being deemed dialysis-intolerant and transitioned to hospice care. She had a history of multiple cardiac devices leading to SVC syndrome, right diaphragmatic paralysis, and progressive dyspnea. Despite being labeled dialysis-dependent, she maintained urine output. Dialysis was discontinued due to recurrent hypotension, assumed to reflect hemodynamic instability. Reevaluation revealed that hypotension was due to chronic volume depletion from over-diuresis. A cautious fluid challenge resulted in improved blood pressure and renal function. Her pacemaker, previously turned off in preparation for hospice, was reactivated and optimized. Imaging confirmed that her dyspnea was mechanical in origin, driven by diaphragmatic paralysis rather than pulmonary edema. Diuretics were reduced, and BiPAP therapy was optimized accordingly. Two years later, she remains dialysis-free (creatinine 1.4 mg/dL, eGFR 50), with stable heart failure and improved respiratory symptoms. She is able to remain a caregiver for her daughter with Down syndrome. Discussion: This case challenges the assumption that dialysis intolerance always indicates end-stage kidney or cardiac failure. Here, hypotension stemmed from treatable volume depletion, not irreversible organ dysfunction. The misinterpretation nearly led to premature palliative transition. Additionally, orthopnea was largely mechanical, due to diaphragmatic dysfunction, not fluid overload which highlights the importance of accurate symptom attribution. Multidisciplinary input was key: Nephrology identified reversible hypovolemia, Cardiology optimized pacing, and Pulmonology clarified the etiology of dyspnea. Moreover, the patient’s personal motivation - her role as primary caregiver for her daughter - reinforces the importance of patient-centered care.