Uremic pericarditis
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.
Overview
Renal failure if not managed adequately can lead to pericardial effusion and pericarditis, also known as uremic pericarditis. This is due to build up of metabolic toxins such as urea, creatinine, methylguanidine which cause inflammation of pericardium. With the introduction of dialysis, the incidence of uremic pericarditis has been considerably lowered[1]. Uremic pericaritis can be further divided as:
- Uremic pericarditis in patients not undergoing dialysis.
- Uremic pericarditis in patients on maintenance dialysis.
Etiology
- Absence of dialysis in renal failure
- Inadequate dialysis in renal failure
- Volume overload during dialysis
- Infections
Pathophysiology
The pathophysiology of uremic pericarditis is not fully understood. However, there is a correlation observed with levels of blood urea nitrogen(usually >60 mg/dL) and creatinine. In renal failure, the absence or inadequate dialysis can lead to accumulation of these toxins in the body which may cause inflammation of pericardium and development of adhesions between the two pericardial layers.
Patients undergoing dialysis may also develop pericarditis. In a series, 13% of patients undergoing hemodialysis developed pericarditis[2]
Uremic pericarditis can occur as serous or hemorrhagic effusion with considerable overlapping. Hemorrhagic effusions are more common secondary to uremia induced platelet dysfunction and the use of anticoagulation during hemodialysis.
Dialysis associated pericarditis may also be secondary to volume overload and bacterial or viral infections[3].
Presence of a large pericardial effusion that persists for >10 days after intensive dialysis has a high likelihood of development of cardiac tamponade
History and symptoms
Patients may present with the following symptoms:
- Fever
- Chest pain that improves on leaning forward and worsens on inspiration
- Breathlessness
- Dizziness
- Malaise
- Ankle edema
Physical examination
Patients present with fever, cachexia and varying degrees of consciousness.
Vitals: Hypotension, pulsus paradoxus (in cardiac tamponade). Heart rate may be slow due to autonomic impairment or arrhythmia may be present due to electrolyte imbalance
Neck: Jugular venous distension with a prominent Y descent and Kussmaul's sign
Chest: Ewart's sign in presence of effusion, pericardial knock, pericardial rub(heard best while leaning forwards) and distant heart sounds
Abdomen: Hepatomegaly, ascites
Extremities: Ankle edema
References
- ↑ Bailey GL, Hampers CL, Hager EB, Merrill JP (1968). "Uremic pericarditis. Clinical features and management". Circulation. 38 (3): 582–91. PMID 5673609.
- ↑ Rutsky EA, Rostand SG (1987). "Treatment of uremic pericarditis and pericardial effusion". Am J Kidney Dis. 10 (1): 2–8. PMID 3605080.
- ↑ Gunukula SR, Spodick DH (2001). "Pericardial disease in renal patients". Semin Nephrol. 21 (1): 52–6. PMID 11172559.