Pericarditis in renal failure
- Robert M Black, MD
Robert M Black, MD
- Professor of Clinical Medicine
- University of Massachusetts Medical Center
Patients with end-stage renal disease (ESRD) may develop pericardial disease, including pericarditis and pericardial effusions, and occasionally chronic constrictive pericarditis [1,2]. Advances in management have decreased the incidence of pericarditis in patients with renal failure, but this problem is still associated with significant morbidity and occasional mortality. Two forms of pericarditis in renal failure have been described.
Uremic pericarditis — Uremic pericarditis results from inflammation of the visceral and parietal membranes of the pericardial sac. There is a correlation with the degree of azotemia (the blood urea nitrogen [BUN] is usually >60 mg/dL [22 mmol/L]), although the pathogenesis is poorly understood. Except in the case of systemic immune disorders (such as lupus erythematosus or scleroderma), there is no relationship with the underlying cause of renal failure.
Dialysis-associated pericarditis — Pericarditis is occasionally observed in patients on maintenance hemodialysis or peritoneal dialysis . At least two factors may contribute to this problem: inadequate dialysis (ie, the patient has uremic pericarditis) and/or fluid overload .
It has been suggested that the two forms of uremic pericarditis in renal failure can be distinguished by the type (serous versus hemorrhagic) of effusion that is present, but there is significant overlap. Pathologic examination of the pericardium typically shows adhesions between the pericardial membranes, which are thicker than normal. Loculated bloody fluid, when present, is due in part to the frequent impairment in platelet function in renal failure and the use of anticoagulation during hemodialysis. (See "Platelet dysfunction in uremia".)
The clinical features of pericarditis in renal failure are similar to those observed with other causes. Most patients complain of fever and pleuritic chest pain, the intensity of which is quite variable . The pain is characteristically worse in the recumbent position. A pericardial rub is generally audible, but is frequently transient. Signs of cardiac tamponade may be seen, particularly in patients with rapid pericardial fluid accumulation. However, the high prevalence of autonomic impairment in this patient population may hinder the normally observed rise in heart rate . Moreover, some patients with uremic pericarditis present without symptoms or suggestive findings (chest pain or pericardial rub) on physical examination . Cardiac ultrasonography reveals a pericardial effusion in at least 50 percent of cases. A concomitant pleural effusion, which is commonly exudative, may be observed, findings consistent with generalized serositis .
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