What is the treatment for uremic pericarditis?

Treatment of Uremic Pericarditis

Intensification of dialysis is the first-line treatment for uremic pericarditis, as it is the most effective intervention to reduce mortality and improve patient quality of life. 1

Diagnostic Considerations

Uremic pericarditis presents with some unique features that distinguish it from other forms of pericarditis:

• Up to 30% of patients may be asymptomatic 1
• Lower incidence of pleuritic chest pain compared to other forms of pericarditis 1
• Often lacks typical ECG alterations seen in other forms of pericarditis 1, 2
• Heart rate may remain slow (60-80 beats/min) during tamponade due to autonomic impairment 3

Treatment Algorithm

First-line Treatment

1. For patients not yet on dialysis:

   • Initiate urgent dialysis 1

2. For patients already on dialysis:

   • Intensify dialysis regimen (more frequent sessions) 1
   • Continue intensive dialysis for 2-3 weeks until complete regression of pericardial effusion 4
   • The average number of dialysis sessions required is approximately 11 4

Second-line Treatment (if intensive dialysis is ineffective)

1. Drainage procedures:

   • Pericardiocentesis for large effusions (>20mm in echocardiography) 3
   • Immediate pericardiocentesis is life-saving in cardiac tamponade 3, 2
   • For massive hemorrhage into the pericardial sac with clotting, pericardiotomy and evacuation of clot may be required 5
   • Consider bilateral partial pericardiectomy in severe cases 6

2. Anti-inflammatory medications:

   • NSAIDs may be considered when intensive dialysis is ineffective 1

     • Ibuprofen is preferred (300-800mg every 6-8 hours) due to favorable coronary flow effects 3
     • Avoid indomethacin in elderly patients due to coronary flow reduction 3
     • Provide gastrointestinal protection when using NSAIDs 3

   • Corticosteroids (systemic or intrapericardial) can be effective 3, 1

     • Intrapericardial application avoids systemic side effects 3

   • Important: Colchicine is contraindicated in patients with severe renal insufficiency 1

Monitoring and Complications

• Monitor for cardiac tamponade, which is more common in dialyzed than non-dialyzed patients 5
• Watch for pericardial constriction, a rare but severe complication 1
• Be vigilant for signs of tamponade even without tachycardia, as uremic patients may not exhibit the typical tachycardic response 3, 2

Clinical Pearls and Pitfalls

• Pitfall: Relying on typical ECG changes to diagnose uremic pericarditis. Unlike other forms of pericarditis, uremic pericarditis often lacks the typical diffuse ST/T wave elevations 3, 2

• Pitfall: Expecting tachycardia during tamponade. Due to autonomic impairment, heart rate may remain slow despite tamponade 3, 2

• Pearl: The prevalence of uremic pericarditis has decreased significantly (from 3-41% to <5%) with improved dialysis techniques, making it a less common diagnosis that requires high clinical suspicion 4, 7

• Pearl: Anemia due to erythropoietin resistance may worsen the clinical picture and should be addressed 3