Uremic Pericarditis

Aka: Uremic Pericarditis, Acute Uremic Pericarditis, Chronic Uremic Pericarditis, Hemodialysis Associated Pericarditis

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II. Pathophysiology

  1. Occurs with Renal Failure related Uremia when GFR falls to <10-15 ml/min (especially in Diabetes Mellitus)
  2. Related to uremic toxins (metabolites, nitrogenous waste) that accumulate and inflame the Pericardium
    1. Fluid and Electrolyte shifts can also trigger Pericarditis
    2. Blood Urea Nitrogen (BUN) levels do not correlate with Uremic Pericarditis symptoms

III. Epidemiology

  1. Incidence as high as 2 to 21% of Hemodialysis patients
    1. Incidence has decreased with advances in Hemodialysis technology and techniques

IV. Types

  1. Uremic Pericarditis
    1. Pericarditis that starts before Hemodialysis is initiated (or within the first 8 weeks of Hemodialysis)
  2. Hemodialysis Associated Pericarditis
    1. Pericarditis that starts more than 8 weeks after Hemodialysis has been initiated
    2. Improves with more frequent Hemodialysis

V. Differential Diagnosis

  1. See Pericarditis Causes

VI. Symptoms

  1. See Pericarditis
  2. Symptomatic onset is typically more insidious and delayed than with other forms of Pericarditis
  3. Pleuritic Chest Pain
  4. Other variably present symptoms
    1. Fever
    2. Malaise
    3. Dyspnea

VII. Signs

  1. Pericardial Friction Rub

VIII. Labs

  1. See Pericarditis
  2. Inflammatory markers
    1. Leukocytosis
    2. C-Reactive Protein increased
    3. Erythrocyte Sedimentation Rate
  3. Serum Troponin
    1. Often elevated in End Stage Renal Disease and may be more difficult to interpret

IX. Diagnostics

  1. See EKG in Pericarditis
  2. Diffuse ST Elevation is often absent in Uremic Pericarditis

X. Imaging

  1. Echocardiogram
    1. Pericardial Effusion is commonly predicted by Hyperkalemia, Hypocalcemia and Tachycardia

XI. Management

  1. Hemodialysis
    1. Hemodialysis (and increased Hemodialysis frequency) is First-line therapy for Uremic Pericarditis
    2. Uremic Pericarditis
      1. Initiate daily Hemodialysis for 5 to 7 days (up to 10 to 14 days)
      2. Those without prior Hemodialysis respond rapidly to the initiation of Hemodialysis within 2 weeks
    3. Hemodialysis Associated Pericarditis
      1. Increased intensity and possibly the frequency and length of Hemodialysis
    4. Complications
      1. Hemorrhagic Tamponade (Anticoagulants used during Hemodialysis)
  2. Medications
    1. Low Dose Corticosteroids (e.g. Prednisone)
      1. Prednisone 0.25 to 0.5 mg/kg/day
    2. Intrapericardial infusion
      1. NSAIDs or Corticosteroids
    3. Avoid contraindicated medications
      1. Avoid Colchicine
      2. NSAIDs
        1. Should be used only with significant caution and in Consultation with nephrology
  3. Interventions
    1. Pericardiocentesis or pericardial window
      1. Indicated in Cardiac Tamponade
    2. Pericardiectomy
      1. Indicated in refractory constrictive Pericarditis

XII. References

  1. Klasek and Alblaihed (2023) Crit Dec Emerg Med 37(6): 4-11
  2. Chugh (2021) Cardiol Rev 29(6): 310-3 [PubMed]
  3. Rehman (2017) Clin Cardiol 40(10): 839-46 [PubMed]

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