Pericardial Involvement
in ESRD
Trina Banerjee
Questions to be Answered

How Should This Pt. Have Been
Treated:
– How often should an echo be done
– What is intensive dialysis
– What is better, intensive dialysis or
pericardial window
Outline of Presentation
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Differential of pericardial dz. in Dialysis
Pts
Uremic Pericarditis
Dialysis Related Pericarditis
Diagnosis
Treatment
Differential of Pericardial
Effusions in Dialysis Pts


Uremic Pericarditis/Pericardial Effusion
Dialysis Related Pericarditis/ Pericardial
Effusion

Volume Overload
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Pericarditis for Other Reasons
Uremic Pericarditis
Definition

Pericarditis either before or within 8
weeks of initiating renal replacement
therapy
Epidemiology

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5% of people with advanced acute or
chronic renal failure
More common in younger patients
More common in women
Pathophysiology I
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Hypothesis is that the pericarditis
arises from accumulation of
biochemical irritants, but the
biochemical irritants are unknown
Calcium alterations, high PTH, and
high uric acid have at various times
been blamed
Pathophysiology II
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Immune complex formation may play a role
Cochran demonstrated impaired fibrinolysis
in patients predialysis and dialysis patients
and implicated this as causative
Abrasion during contractions would extend
the serositis and could lead to effusion
Clinical Presentation

Pleuritic Pain (32-82% of patients)

Friction Rub (31-100% of patients)
Dialysis Related
Pericarditis
Definition

Pericarditis after 8 weeks of renal
replacement therapy
Epidemiology

More common in younger patients

More common in women
Pathophysiology I

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Uncertain if pathophysiology is the
same as in uremic pericarditis
May be secondary to relatively
inadequate dialysis
Pathophysiology II

Associated with the following:
– Inadequate dialysis
– Hypercatabolic conditions
– Hyperparathyroidism
– Infection (especially viral)
Clinical Presentation
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Thoracic Pain (41100%)
Cough or dyspnea
(31-57%) (93%
with tamponade)
Malaise (54-66%)
Weight Loss (40%)
Fever (75-100%)
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Chills (68%)
Friction Rub (59100%)
Gallop Rhythm
(66%)
JVD (68-88%)
Hepatomegaly
(68%)
Diagnosis
Diagnosis

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EKG does not show typical ST segment
and T wave changes
Echo is used to assess the size of the
effusion
Treatment
Uremic Pericarditis
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If hemodynamically unstable needs
surgical intervention
Dialysis with either HD or PD causes
rapid improvement
If fails to resolve in 7-10 days needs
surgical intervention
Important Facts about
Dialysis
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Resolution rate 76-100%
15% recurrence rate
Systemic anticoagulation should be
avoided because of the high risk of
hemorrhage
Acute fluid removal can lead to
cardiovascular collapse in tamponade
Dialysis Related
Pericardial Effusion
Treatment Depends on
Size

Large (>250cc pericardial effusion)
– Drainage
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Medium and Small Effusions
– Intensive Dialysis vs. Drainage
Large Effusions
Drainage Modality Depends
on Hemodynamics
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Acute Tamponade or rapidly
accumulating effusion
– Pericardiocentesis
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Stable Large Effusion
– Subxiphoid Pericardiotomy or
Pericardiostomy
– Pericardial Window
– Pericardiectomy
Pericardiocentesis
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Involves putting a needle into the
pericardium
Recurrence rates as high as 70%
Mortality rate 3-50%
Complications include: Mycocardial
laceration, Coronary artery laceration,
and precipitation of tamponade
Subxiphoid Pericardiotomy
or Pericardiostomy I
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Pericardiotomy is the incision of the
pericardium
Pericardiostomy is the installation of a
catheter after the incision through
which steroids are infused
Subxiphoid Pericardiotomy
or Pericardiostomy II

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Performed under local anesthesia
Intrapericardial catheter can be placed
for drainage and steroid installation
(triamcinolone hexacetonide 50 mg q6
for 2-3 days)
Rutsky and Rostand
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Looked at 13 patients with dialysis
related pericardial effusion treated
with pericardiostomy and steroids
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100% were effective
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1 recurrence
Pericardial Window
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Either subxiphoid or left thoractotomy
approach
In Subxiphoid a 5cm 2 patch of pericardium
is resected and a sump drain is attached
with suction of 10-20mm Hg
Drain is removed when the output of the
tube is 50-100 mm Hg, usually in 3-4 days
Left thoracotomy approach is used a
variable sized window is created and chest
tubes are inserted, usually for 4-5 days
Pericardiectomy
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Performed under general anesthesia

Thoracotomy Approach
Figuera Study I
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57 ESRD patients with large pericardial
effusions between 1/1980 and
12/1991
5 patients had uremic pericarditis
52 patients had dialysis related
pericardial effusions
Echo showed more than 300-500 cc of
fluid
Figuera II
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7 patients underwent pericardiectomy
50 patients underwent subxiphoid
pericardial window and fluid drainage
None of the 50 patients who had pericardial
windows had major surgical complications
All patients were followed on dialysis
afterwards and none had recurrence of
effusion
Small and Medium
Effusions
Intensive Hemodialysis

Definition:
– Intensive dialysis is considered 4 hours a
day for 10-14 days (Semin Dial. 1990;
3:21–25)
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Problems:
– Anticoagulation should not be used
– Hemodynamic shifts may be harmful
– Electrolyte abnormalities
Predictors of Poor Response
to Intensive Hemodialysis
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T>102
Systolic BP <100
WBC>15
JVD, large pericardial effusion, and/or
anterior and posterior pericardial
effusions on the TTE
Echo Frequency with
Intensive Dialysis
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Standard practice is to repeat echo
every 3-5 days during intensive
dialysis to assess for change in volume
Medical Management
NSAIDs
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Spektor Trial:
– Prospective double blind of 24 patients
– 21 dialysis pericarditis, 3 uremic pericarditis
– No difference in the duration of pleuritic chest
pain, friction rub, amount of pericardial effusion,
or need for invasive surgical procedures between
those treated with indomethacin 25mg PO qid
and those treated with placebo
NSAIDs
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Rutsky and Rostand
– Patients with dialysis pericarditis
– 40 Treated with NSAIDs
– 121 not
– No clinical difference
Steroids
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Compty:
– 8 patients with dialysis pericarditis
– Treated with 20 to 60 mg of prednisone
per day for 1 to 12 weeks
– 7 of the 8 had their clinical manifestations
of pericarditis normalize within 1-3 weeks
Steroids
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Eliason:
– No clinical improvement and increase in
infection and wound dehiscence after
steroids