Uremic pericarditis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.

Renal failure can be associated with the development of a pericardial effusion and pericarditis, a condition known as uremic pericarditis. The underlying pathophysiology is not entirely clear, but it is hypothesized that uremic pericarditis is due to a 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 dropped^[1].

Signs and symptoms of pericarditis may be similar to several other conditions including myocardial infarction, aortic dissection and pulmonary embolism which are life threatening and therefore it is important to differentiate them. Pain along the trapezius ridge, which is unresponsive to vasodilator therapy and varies with position, is a specific sign of pericarditis.

Non-specific markers of inflammation are generally elevated in pericarditis. These include the leukocyte count, C-reactive protein, and ESR. The cardiac troponin is elevated if there is an injury to the underlying myocardium, a condition termed as myopericarditis. Diagnostic pericardiocentesis and biopsy help in identifying an underlying infectious or malignant process.

Echocardiogram may show presence of fluid surrounding the heart in pericardial effusion. Loculated effusions secondary to adhesions in pericardial cavity may also be visualized as shown in the video below. Swinging motion of the heart may be seen in patients with cardiac tamponade.

On CT, pericardial fluid adds to the thickness of pericardium as both have the similar signal intensities. In pericarditis, pericardium can generate an intermediate signal intensity and may enhance after gadolinium administration. In pericardial effusion, hemorrhagic effusions can be differentiated from a transudate or an exudate based on signal characteristics (high signal on T1-weighted images) or density (high-density clot on CT). CT is superior to MRI in the visualization of pericardial calcification which is often seen in the patient with pericardial constriction. CT imaging also helps in detecting the presence of tumors and the extent of metastasis of the neoplasm.

On MRI, normal pericardium appears as a thin dark band that is bordered by a bright band on both sides on T1 weighted spin imaging. These surrounding bright bands are associated with the surrounding epicardial and pericardial fat. Following the administration of gadolinium, pericardium may appear thick and inflamed in the setting of pericarditis. Lower intensity signal is observed in constrictive pericarditis than in acute pericarditis. Comprehensive visualization of the LV endocardium and the physiologic consequences of abnormal pericardial thickening can also be obtained without exposure to ionizing radiation.^[2]

In presence Cardiac tamponade, there is equalization of pressures in all four chambers of heart. The right atrial pressure equals the right ventricular end diastolic pressure equals the pulmonary artery diastolic pressure.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

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. This could lead to loculation of effusion in pericardial cavity. Patients undergoing dialysis may also develop pericarditis. In a series, 13% of patients undergoing hemodialysis developed pericarditis.

• 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. This could lead to loculation of effusion in pericardial cavity.
• Patients undergoing dialysis may also develop pericarditis. In a series, 13% of patients undergoing hemodialysis developed pericarditis^[1]
• Uremic pericarditis can occur as a serous or a 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.^[2]
• Presence of a large pericardial effusion that persists for >10 days after intensive dialysis has a high likelihood of development of cardiac tamponade.

Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

Images courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Disease name] may be caused by Chronic renal failure

OR

Common causes of [disease] include [cause1], [cause2], and [cause3].

OR

The most common cause of [disease name] is [cause 1]. Less common causes of [disease name] include [cause 2], [cause 3], and [cause 4].

OR

The cause of [disease name] has not been identified. To review risk factors for the development of [disease name], click here.

• Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. There are no life-threatening causes of disease name, however complications resulting from untreated disease name is common.
• Life-threatening causes of [symptom/manifestation] include [cause1], [cause2], and [cause3].
• [Cause] is a life-threatening cause of [disease].

Common causes of uremic pericarditis include:

• Chronic renal failure
• The causes of chronic renal failure include:
  • Diabetes mellitus
  • Lupus nephritis
  • Membranoproliferative glomerulonephritis
  • Focal segmental glomerulosclerosis
  • Multiple myeloma

Less common causes of uremic pericarditis include less common causes of chronic renal failure that includes:

• Goodpasture syndrome
• IgA nephropathy

List the causes of the disease in alphabetical order:

Template:WH Template:WS

• Absence of dialysis in renal failure
• Inadequate dialysis in renal failure
• Volume overload during dialysis
• Infections

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]; Associate Editor(s)-in-Chief: Syed Hassan A. Kazmi BSc, MD [3] Homa Najafi, M.D.[4]

Pericarditis must be differentiated from diseases presenting with chest pain, shortness of breath and tachypnea which include myocardial infarction, pulmonary embolism, congestive heart failure, pneumonia, vasculitis, and chronic obstructive pulmonary disease (COPD). Manifestation of the pericarditis can help in differentiation from myocardial infarction. Moreover, other differential diagnosis include aortic stenosis, coronary artery vasospasm, esophageal rupture, esophageal spasm, esophagitis,acute gastritis, gastroesophageal reflux disease, and peptic ulcer disease should be considered.

• Pericarditis must be differentiated from diseases presenting with chest pain, shortness of breath and tachypnea.
  • For a full discussion of the differential diagnosis of chest pain click here
  • For an expert algorithm that aids in the diagnosis of the cause of chest pain click here
• Pericarditis must be differentiated from myocardial infarction as an important cause of chest pain.The differentiating features include:^[1]

The differentials include the following:^{[2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20][21]}

Pericarditis also resembles the following disorders and needs to be differentiated from them:

Template:WH Template:WS

​

Please help WikiDoc by adding more content here. It’s easy! Click here to learn about editing.

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

Pericarditis in renal failure occurs in approximately in 13 percent of patients who are on maintenance hemodialysis^[1]. Hyperurcemia due to inadequate dialysis or fluid overload may be the reason for pericarditis^[2].

Uremic pericarditis can occur as a serous or a 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 bacterial or viral infections^[3].

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

OR

Common complications of [disease name] include [complication 1], [complication 2], and [complication 3].

OR

Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [#]%.

• The symptoms of (disease name) usually develop in the first/ second/ third decade of life, and start with symptoms such as ___.
• The symptoms of (disease name) typically develop ___ years after exposure to ___.
• If left untreated, [#]% of patients with [disease name] may progress to develop [manifestation 1], [manifestation 2], and [manifestation 3].

Click on the blue links below to read more about specific complications of uremic pericarditis:

Uremic pericarditis often can be complicated by significant fluid buildup around the heart, a condition known as a pericardial effusion.

If the fluid accumulates too rapidly or is too large, then cardiac tamponade, a condition in which the heart is compressed by the fluid and cannot pump enough blood forward may occur. Cardiac tamponade may require urgent intervention including pericardiocentesis. This complication is more common in patients with specific underlying etiologies such as malignancy, tuberculosis^[1], or purulent pericarditis and rarely occurs in idiopathic pericarditis.

If scarring of the sac around the heart (the pericardium) occurs, then this is called constrictive pericarditis which may require surgical stripping of the scar (pericardiectomy).

Uremic pericarditis may lead to hemorrhagic pericarditis and is associated with significant morbidity and poor prognosis^[2].

• Prognosis is generally excellent/good/poor, and the 1/5/10-year mortality/survival rate of patients with [disease name] is approximately [–]%.
• Depending on the extent of the [tumor/disease progression] at the time of diagnosis, the prognosis may vary. However, the prognosis is generally regarded as poor/good/excellent.
• The presence of [characteristic of disease] is associated with a particularly [good/poor] prognosis among patients with [disease/malignancy].
• [Subtype of disease/malignancy] is associated with the most favorable prognosis.
• The prognosis varies with the [characteristic] of tumor; [subtype of disease/malignancy] have the most favorable prognosis.

Template:WH Template:WS

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Varun Kumar, M.B.B.S.; Lakshmi Gopalakrishnan, M.B.B.S.

• Patient with uremic pericarditis should be treated with intensive hemodialysis which would most often results in resolution of pericardial effusion and chest pain^[1][2]within 1-2 weeks. Pericardiocentesis can be done to drain effusion if it is causing hemodynamic compromise such as in cardiac tamponade. Use of heparin free hemodialysis is adviced to prevent development of hemopericardium.

• Hypokalemia and hypophosphatemia should be prevented by supplementing the dialysis solution when appropriate^[3].

• NSAIDs may be used in treatment of chest pain secondary to pericarditis. In case of recurrent pericardial effusion, pericardiotomy where a pericardial window for drainage of effusion may be made. In large refractory effusion, intra pericardial instillation of non-absorbable corticosteroids may be considered^[4][5].

• Pericardiectomy should be done in refractory and severely symptomatic patients.

• Appropriate antivirals or antibiotics should be used in treatment of infective pericarditis which may occur in immunocompromised states resulting after renal transplantation^[6].

[[Category:Up-To-Date cardiology]

Template:WH Template:WS