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Nephrology > Chronic Kidney Disease
Pericarditis, Uremic
Article Last Updated: Nov 16, 2006
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: Anupama Gowda, MBBS, MD, Consulting Staff, Atlanta Nephrology Associates, PC
Coauthor(s):
Chike Magnus Nzerue, MD, Chief, Nephrology Unit, Harbin Clinic
Editors: James W Lohr, MD, Fellowship Program Director, Professor, Department of Internal Medicine, Division of Nephrology, State University of New York at Buffalo; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; George R Aronoff, MD, Director, Professor, Departments of Internal Medicine and Pharmacology, Section of Nephrology, Kidney Disease Program, University of Louisville School of Medicine; Rebecca J Schmidt, DO, FACP, FASN, Professor of Medicine, Section Chief, Department of Medicine, Section of Nephrology, West Virginia University School of Medicine; Vecihi Batuman, MD, FACP, FASN, Professor of Medicine, Section of Nephrology-Hypertension, Tulane University School of Medicine; Chief, Medicine Service, Southeast Louisiana Veterans Health Care System
Author and Editor Disclosure
Synonyms and related keywords:
uremic pericarditis, uremic pericardial serositis, renal failure, pericardium, dialysis-associated pericarditis, urea, creatinine, methylguanidine, guanidinoacetate, parathyroid hormone, beta2-microglobulin, uric acid, azotemia, hemorrhagic effusion, serous effusion, cardiac tamponade, arrhythmias, pleuritic chest pain, renal transplantation, idiopathic pericarditis, heparin-free hemodialysis, pericardiocentesis, subxiphoid pericardiotomy, pericardiectomy, pulsus paradoxus, uremia
Background
Richard Bright first described uremic pericarditis 163 years ago. Since that classic description, this common complication of chronic renal failure has evolved from an ominous event heralding the terminal stages of disease to an event that, with early management, is likely to have a good outcome. Furthermore, advances in dialysis technology with early and auspicious management of chronic renal failure have dramatically reduced the prevalence of uremic pericarditis. Uremic pericarditis has a prevalence of 6-10% in patients with acute or chronic renal failure, and it continues to be associated with significant morbidity and occasional mortality.
Pathophysiology
Uremic pericarditis is thought to result from inflammation of the visceral and parietal layers of the pericardium by metabolic toxins that accumulate in the body owing to kidney failure. Other factors may be involved, however, because pericarditis also may occur in patients with chronic renal failure who already are receiving dialysis therapy.
The putative toxins suggested to precipitate uremic pericarditis when they accumulate are poorly characterized, but they may include urea, creatinine, methylguanidine, guanidinoacetate, parathyroid hormone, beta2-microglobulin, uric acid, and others. More than one toxin apparently may be involved, though considerable controversy surrounds this point.
The precise pathogenetic changes induced by these toxins when causing uremic pericarditis have not been elucidated, though a rough correlation with the degree and duration of azotemia exists. Histopathological examination often reveals adhesions between the pericardial membranes, which are thickened. Uremic pericarditis may be associated with hemorrhagic or serous effusion, although considerable overlap exists. Hemorrhagic effusions are more common and result in part from uremia-induced platelet dysfunction.
Some authors distinguish between 2 types of pericarditis in patients with renal failure. One type is uremic pericarditis, which occurs in patients with uremia who have never received dialysis. The other type is dialysis-associated pericarditis, which occurs in patients who are already receiving dialysis. In the latter case, inadequate dialysis may usually be implicated because aggressive dialysis often leads to resolution. Other causes of dialysis-associated pericarditis may include volume overload and bacterial or viral infections.
Frequency
United States
Uremic pericarditis may occur in 6-10% of patients with advanced renal failure before initiation of dialysis. When patients with large effusions are studied, uremia may account for up to 20% of cases in some series. The widespread availability of dialysis has reduced the incidence of uremic pericarditis.
Mortality/Morbidity
- Uremic pericarditis continues to be associated with significant morbidity and occasional mortality.
- Mortality may occur in 3-5% of cases resulting from cardiac tamponade or arrhythmias.
- During dialysis, frequent monitoring of electrolytes is helpful to detect and treat hypokalemia and hypophosphatemia, especially in patients with dialysis-associated pericarditis.
History
Patients with uremic pericarditis often complain of chest pain. This chest pain characteristically is pleuritic and is worse in the recumbent position, but it is relieved by leaning forward. Some patients may have fever. Patients with sizable effusions may present with dyspnea. Palpitations may be the presenting complaint.
Physical
On examination, patients with uremic pericarditis may have tachycardia or hypotension in cases with impending tamponade. A pericardial friction rub is present in most cases, but the rub may be transient. Signs of tamponade, including inspiratory jugular venous distension and paradoxical pulse, also may be present. Aside from the cardiac findings, patients may be febrile and present with confusion.
Angina Pectoris
Aortic Dissection
Aortic Stenosis
Gastroesophageal Reflux Disease
Myocardial Infarction
Pulmonary Embolism
Other Problems to be Considered
- Pericarditis may occur after renal transplantation. In this case, it may be related to uremia or infections (eg, cytomegalovirus [CMV]).
- Idiopathic pericarditis
- Constrictive pericarditis
- Purulent pericarditis
Lab Studies
- Serum urea nitrogen and serum creatinine levels are elevated (azotemia).
- Determine serum electrolyte (ie, sodium, potassium, chloride, magnesium, calcium, phosphate) concentrations because of the increased risk of cardiac arrhythmias in patients with pericarditis.
- Obtain serum creatine kinase concentrations with isoenzymes, troponin, and lactate dehydrogenase (LDH) levels in order to exclude myocardial infarction.
- Obtain CBC count. Significant leukocytosis may be present with either an inflammatory or infective cause of pericarditis. Serially monitor hemoglobin and hematocrit values. Transfuse patients with a hemoglobin value less than 8 g because this improves the abnormalities of hemostasis associated with uremia. Monitor the platelet count.
- Determine prothrombin time/activated partial thromboplastin time (PT/aPTT) and, if abnormal, correct in order to lessen the chance of developing tamponade.
Imaging Studies
- Chest radiograph examination often reveals an enlarged boot-shaped cardiac profile.
- Ultrasonography is helpful in confirming the diagnosis, particularly if cardiac tamponade is suspected.
Other Tests
- ECG often fails to demonstrate the diffuse ST- and T-wave elevations observed in idiopathic pericarditis. In fact, the presence of these changes on ECG mandates a search for an alternative cause for pericarditis. ECG is very useful to identify the presence of effusion and to help exclude tamponade.
Histologic Findings
Adhesions are present between the pericardial membranes. The effusions frequently are bloody.
Medical Care
The development of pericarditis in a patient with severe acute or chronic renal failure is an absolute indication for dialysis. In most patients, relief of chest pain and reduction in the size of any effusion occurs within 1-2 weeks.
- Both hemodialysis and peritoneal dialysis are efficacious in treatment of uremic pericarditis, though each technique has unique advantages and disadvantages.
- Hemodialysis may cause hypotension, which may be dangerous in the setting of tamponade. In addition, some physicians advocate heparin-free hemodialysis to reduce the risk of intrapericardial hemorrhage.
- Peritoneal dialysis may compromise respiratory function because of the effect of intraperitoneal fluid on the diaphragm.
- In dialysis-associated pericarditis, an increased intensity of dialysis for 10-14 days is recommended. Close monitoring of fluid volume and electrolytes is mandatory to detect and correct hypophosphatemia and hypokalemia, which may occur with intensive dialysis. The response of dialysis-associated pericarditis is not predictable. In some instances, consider a switch to peritoneal dialysis.
- Nonsteroidal anti-inflammatory drugs (NSAIDS) and steroids may offer symptomatic relief but are not effective without dialysis. Indomethacin ameliorates fever, but it does not accelerate resolution of the effusion.
Surgical Care
- People with effusions larger than 250 mL, effusions in which size increases despite intensive dialysis for 10-14 days, or effusions with evidence of tamponade are candidates for pericardiocentesis.
- Pericardial window is a modification of balloon valvuloplasty in which an uninflated balloon is passed inside the pericardial space, where it is opacified, inflated, and then pulled through the pericardium to create a window through which pericardial fluid drains into the peritoneal or pleural space.
- Subxiphoid pericardiotomy may be performed under local anesthesia and has a lower risk of complications compared to pericardiectomy. Consider subxiphoid pericardiotomy for large effusions that do not resolve.
- Pericardiectomy is the most effective surgical procedure for managing large effusions because it has the lowest associated risk of recurrent effusions. Pericardiectomy requires general anesthesia and a thoracotomy.
Consultations
- Consult with a cardiologist for evaluation with echocardiogram.
- Consult with a cardiothoracic surgeon for all patients with large effusions. Development of tamponade is unpredictable, and it is important for the surgeon to be aware of the patient if an emergent procedure is necessary.
Diet
Patients on dialysis require a daily diet restricted to 1.2 g/kg of protein, 2 g of sodium, and 2 g of potassium. Patients on peritoneal dialysis may require less stringent protein restriction.
Activity
Activity should be limited to avoid strenuous activities or trauma, which may increase the risk of hypotension or arrhythmias.
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Drug Category: Nonsteroidal anti-inflammatory drugs
May offer symptomatic relief but are ineffective in absence of dialysis.
| Drug Name | Indomethacin (Indocin) |
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| Description | Often considered the first choice. Rapidly absorbed, and metabolism occurs in liver by demethylation, deacetylation, and glucuronide conjugation. Inhibits prostaglandin synthesis. Demonstrated to ameliorate fever but does not accelerate resolution of effusion. |
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| Adult Dose | 25-50 mg PO q6h |
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| Pediatric Dose | 1-2 mg/kg/d PO divided bid/qid; not to exceed 4 mg/kg/d or 150-200 mg/d |
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| Contraindications | Documented hypersensitivity, peptic ulcer disease, recent GI bleeding or perforation, renal insufficiency |
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| Interactions | Coadministration with aspirin increases risk of inducing serious NSAID-related adverse effects; probenecid may increase concentrations and, possibly, toxicity of NSAIDs; may decrease effect of hydralazine, captopril, and beta-blockers; may decrease diuretic effects of furosemide and thiazides; monitor PT closely (instruct patients to watch for signs of bleeding); may increase risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Category D in third trimester of pregnancy; acute renal insufficiency, hyperkalemia, hyponatremia, interstitial nephritis, and renal papillary necrosis may occur; increases risk of acute renal failure in patients with preexisting renal disease or compromised renal perfusion; reversible leukopenia may occur; discontinue if persistent leukopenia, granulocytopenia, or thrombocytopenia occurs |
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Drug Category: Corticosteroids
May offer symptomatic relief but are ineffective in the absence of dialysis.
| Drug Name | Prednisone (Deltasone, Sterapred, Orasone) |
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| Description | May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. |
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| Adult Dose | 5-60 mg/d PO or divided bid/qid, taper over 2 wk as symptoms resolve |
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| Pediatric Dose | 4-5 mg/m2/d PO; alternatively, 0.05-2 mg/kg PO divided bid/qid; taper over 2 wk as symptoms resolve |
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| Contraindications | Documented hypersensitivity, viral infection, peptic ulcer disease, hepatic dysfunction, connective tissue infections, fungal or tubercular skin infections, GI disease |
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| Interactions | Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics |
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| Pregnancy | B - Usually safe but benefits must outweigh the risks.
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| Precautions | Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use |
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Further Inpatient Care
- Patients with significant effusion requiring medical or surgical therapy require admission to the hospital.
Further Outpatient Care
- Carefully monitor the patient at follow-up hemodialysis visits for recurrence of signs or symptoms. Up to 15% of patients may have recurrence of pericarditis.
Transfer
- Patients may require transfer to a hospital setting in which hemodialysis and cardiothoracic surgery are available.
Deterrence/Prevention
- Early intervention with dialysis may prevent the development of uremic pericarditis. Maintenance of adequate dialysis therapy lessens the likelihood of a patient developing dialysis-associated pericarditis.
Complications
- Pericardial tamponade
- Pulsus paradoxus is an inspiratory fall in systolic arterial blood pressure of greater than 10 mm Hg. It occurs in 70-80% of patients with pericardial tamponade.
- It also occurs in patients with severe asthma, constrictive pericarditis, and severe congestive heart failure.
Prognosis
- Three to 5% of patients with uremic pericarditis may develop hemorrhagic pericarditis.
Patient Education
- Instruct patients to call their physician should symptoms recur.
Medical/Legal Pitfalls
- Failure to diagnose uremic pericarditis in a timely manner could result in significant morbidity and occasional mortality.
| Media file 1:
Chest radiographs revealing markedly enlarged cardiac silhouette and normal-appearing lung parenchyma in prepericardiocentesis (A) and postpericardiocentesis (B). Courtesy of Zhi Zhou, MD. |
 |  View Full Size Image | |
Media type: X-RAY
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| Media file 2:
Recording of aortic pressure showing pulsus paradoxus. During inspiration, systolic pressure declines 20 mm Hg. Courtesy of Zhi Zhou, MD. |
 | View Full Size Image | |
Media type: Graph
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Pericarditis, Uremic excerpt Article Last Updated: Nov 16, 2006
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