What are the signs and treatment of uremic pericarditis?

Signs and Treatment of Uremic Pericarditis

Uremic pericarditis presents with atypical clinical features compared to other forms of pericarditis, including absence of tachycardia during tamponade and non-characteristic ECG changes in patients with advanced renal failure (BUN >60 mg/dL). 1

Clinical Signs and Presentation

Typical Signs

• Pericardial friction rub - May persist even with large effusions or be transitory 1
• Chest pain - Pleuritic in nature, but present in only a portion of patients 2
• Dyspnea - Progressive shortness of breath 2
• Fever - May be present but not universal 1

Atypical Features (Distinguishing from Other Forms of Pericarditis)

• Asymptomatic presentation - Up to 30% of patients may be asymptomatic 1
• Absence of tachycardia during tamponade - Heart rate may remain slow (60-80 beats/min) despite fever and hypotension 1, 3
• Normal or non-specific ECG - Typically without the diffuse ST/T segment elevations seen in other forms of acute pericarditis 1, 3
• Lower rate of pleuritic chest pain - Only about 70% of patients experience this symptom 2

Physical Examination Findings

• Neck vein distension with elevated jugular venous pressure
• Pulsus paradoxus (if tamponade develops)
• Diminished heart sounds with moderate to large effusions 2
• Pericardial friction rub (may be mono-, bi-, or triphasic) 2

Diagnostic Evaluation

Laboratory Tests

• Renal function tests - BUN >60 mg/dL correlates with uremic pericarditis 1
• Serum creatinine - Elevated in renal failure 1
• Electrolytes - Particularly potassium (often elevated) 1
• Complete blood count - May show anemia due to erythropoietin resistance 1
• Inflammatory markers - CRP may be elevated 2

Imaging

• Echocardiography - Essential for detecting:
  • Size of pericardial effusion
  • Signs of tamponade
  • Cardiac function
  • Pericardial thickening (>3mm) 1
• Chest X-ray - May show enlarged cardiac silhouette 2
• Renal ultrasound - To evaluate kidney size, structure and rule out obstruction 1

Treatment

Primary Management

• Dialysis - The cornerstone of treatment 2, 1
  • Intensification of dialysis should be considered in patients already on dialysis 2
  • Typically requires 2-3 weeks of dialysis until complete regression of pericardial effusion 4
  • Average of 11±3.5 dialysis sessions needed for resolution 4

Management of Complications

• Pericardiocentesis or drainage - Indicated for:
  • Non-responsive patients despite adequate dialysis 2
  • Cardiac tamponade (occurs in 31-37% of cases) 1, 4
  • Hemodynamically significant effusions 2
• Surgical intervention - May be required for:
  • Loculated effusions (subxiphoid pericardiostomy) 2
  • Constrictive pericarditis (rare but serious complication) 1

Medications

• NSAIDs and corticosteroids - May be considered when intensive dialysis is ineffective 2
• Colchicine - Contraindicated in patients with severe renal impairment 2

Epidemiology and Prognosis

• Prevalence has decreased from 3-41% to <5% in recent decades due to improvements in hemodialysis 1, 4
• Two distinct forms exist:
  • Uremic pericarditis: Occurs in 6-10% of patients with advanced renal failure before or shortly after dialysis initiation
  • Dialysis-associated pericarditis: Affects up to 13% of patients on maintenance hemodialysis 1
• Prognosis depends on early diagnosis and adequate treatment of ESRD 4

Complications to Monitor

• Cardiac tamponade (requiring urgent intervention)
• Chronic pericardial effusion due to continuous volume overload
• Constrictive pericarditis (rare)
• Hemorrhagic effusion (pericardial effusion is often bloody in uremic patients) 2

Early recognition and prompt initiation of dialysis are essential to prevent life-threatening complications of uremic pericarditis.