Uremic Pericarditis

Introduction

Uremic pericarditis is an inflammation of the pericardium (the sac surrounding the heart) that occurs in patients with advanced kidney disease, particularly in those with uremia (a condition caused by high levels of uremic toxins in the blood due to renal failure). This condition can lead to serious complications, including cardiac tamponade, a life-threatening emergency.

Causes and Pathophysiology

Uremic pericarditis typically develops in patients with end-stage renal disease (ESRD) who have inadequate dialysis or have not yet started dialysis. The primary cause is the accumulation of uremic toxins that cause inflammation of the pericardium.

Risk Factors:

• Chronic kidney disease (CKD), especially in late stages (stage 4-5)
• Poorly controlled uremia
• Inadequate dialysis or delayed initiation of dialysis
• Secondary infections or metabolic disturbances

Symptoms

Patients with uremic pericarditis often experience: - Chest pain, which may be sharp and pleuritic (worse with breathing or lying down) - Pericardial friction rub, a characteristic sound heard with a stethoscope - Fever (less common in uremic pericarditis compared to infectious pericarditis) - Dyspnea (shortness of breath) - Signs of pericardial effusion (fluid accumulation in the pericardial sac), which can progress to cardiac tamponade

Diagnosis

Clinical Evaluation:

• History and Physical Examination: Look for signs of chest pain, rubs, and effusion.
• Electrocardiogram (ECG): May show non-specific ST-T changes.
• Echocardiography: The most important test for detecting pericardial effusion or tamponade.
• Blood Tests: Elevated blood urea nitrogen (BUN) and creatinine levels confirm renal failure.
• Chest X-ray: May show an enlarged cardiac silhouette if significant pericardial effusion is present.

Treatment

Dialysis Optimization

• The primary treatment is intensive dialysis to remove uremic toxins.
• If the patient is not on dialysis, urgent initiation of hemodialysis may be necessary.

Anti-inflammatory Therapy

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Generally avoided due to their nephrotoxicity.
• Colchicine: May be used in selected cases.

Treatment of Pericardial Effusion

• If a large pericardial effusion or signs of tamponade are present, pericardiocentesis (drainage of pericardial fluid) is required.
• Pericardial window surgery may be needed in recurrent cases.

Prognosis

• With appropriate dialysis, uremic pericarditis often resolves within a few weeks.
• If left untreated, it may lead to cardiac tamponade and death.

Conclusion

Uremic pericarditis is a serious manifestation of advanced kidney disease. Early recognition and aggressive dialysis treatment are key to preventing severe complications. Patients with ESRD should have regular monitoring, and any new-onset chest pain should be urgently evaluated for pericardial involvement.

Source recommendations

1. American Heart Association Guidelines on Pericardial Disease

1. https://www.ahajournals.org/doi/10.1161/circulationaha.105.561514
2. https://www.sciencedirect.com/science/article/abs/pii/S1936878X24001608
3. https://www.jacc.org/doi/10.1016/j.jacc.2019.11.021
4. https://www.heart.org/en/health-topics/pericarditis/what-is-pericarditis
5. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2015/10/30/12/01/2015-esc-guidelines-for-the-diagnosis-and-management-of-pericardial-diseases

2. European Society of Cardiology Guidelines on Pericardial Diseases

1. https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Pericardial-Diseases-Guidelines-on-the-Diagnosis-and-Management-of
2. https://academic.oup.com/eurheartj/article/36/42/2921/2293375
3. https://pubmed.ncbi.nlm.nih.gov/26320112/
4. https://www.escardio.org/Working-groups/Working-Group-on-Myocardial-and-Pericardial-Diseases/Publications/Paper-of-the-Month/2015-esc-guidelines-on-the-diagnosis-and-management-of-pericardial-diseases
5. https://www.acc.org/latest-in-cardiology/ten-points-to-remember/2015/10/30/12/01/2015-esc-guidelines-for-the-diagnosis-and-management-of-pericardial-diseases