II. Pathophysiology
- Occurs with Renal Failure related Uremia when GFR falls to <10-15 ml/min (especially in Diabetes Mellitus)
- Related to uremic toxins (metabolites, nitrogenous waste) that accumulate and inflame the Pericardium
- Fluid and Electrolyte shifts can also trigger Pericarditis
- Blood Urea Nitrogen (BUN) levels do not correlate with Uremic Pericarditis symptoms
III. Epidemiology
-
Incidence as high as 2 to 21% of Hemodialysis patients
- Incidence has decreased with advances in Hemodialysis technology and techniques
IV. Types
- Uremic Pericarditis
- Pericarditis that starts before Hemodialysis is initiated (or within the first 8 weeks of Hemodialysis)
- Hemodialysis Associated Pericarditis
- Pericarditis that starts more than 8 weeks after Hemodialysis has been initiated
- Improves with more frequent Hemodialysis
V. Differential Diagnosis
VI. Symptoms
- See Pericarditis
- Symptomatic onset is typically more insidious and delayed than with other forms of Pericarditis
- Pleuritic Chest Pain
- Other variably present symptoms
VII. Signs
VIII. Labs
- See Pericarditis
- Inflammatory markers
- Serum Troponin
- Often elevated in End Stage Renal Disease and may be more difficult to interpret
IX. Diagnostics
- See EKG in Pericarditis
- Diffuse ST Elevation is often absent in Uremic Pericarditis
X. Imaging
-
Echocardiogram
- Pericardial Effusion is commonly predicted by Hyperkalemia, Hypocalcemia and Tachycardia
XI. Management
-
Hemodialysis
- Hemodialysis (and increased Hemodialysis frequency) is First-line therapy for Uremic Pericarditis
- Uremic Pericarditis
- Initiate daily Hemodialysis for 5 to 7 days (up to 10 to 14 days)
- Those without prior Hemodialysis respond rapidly to the initiation of Hemodialysis within 2 weeks
- Hemodialysis Associated Pericarditis
- Increased intensity and possibly the frequency and length of Hemodialysis
- Complications
- Hemorrhagic Tamponade (Anticoagulants used during Hemodialysis)
- Medications
- Low Dose Corticosteroids (e.g. Prednisone)
- Prednisone 0.25 to 0.5 mg/kg/day
- Intrapericardial infusion
- NSAIDs or Corticosteroids
- Avoid contraindicated medications
- Avoid Colchicine
- NSAIDs
- Should be used only with significant caution and in Consultation with nephrology
- Low Dose Corticosteroids (e.g. Prednisone)
- Interventions
- Pericardiocentesis or pericardial window
- Indicated in Cardiac Tamponade
- Pericardiectomy
- Indicated in refractory constrictive Pericarditis
- Pericardiocentesis or pericardial window
XII. References
- Klasek and Alblaihed (2023) Crit Dec Emerg Med 37(6): 4-11
- Chugh (2021) Cardiol Rev 29(6): 310-3 [PubMed]
- Rehman (2017) Clin Cardiol 40(10): 839-46 [PubMed]