Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Pericarditis in renal failure

Robert M Black, MD
Section Editor
Jeffrey S Berns, MD
Deputy Editor
Alice M Sheridan, MD


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 [3]. At least two factors may contribute to this problem: inadequate dialysis (ie, the patient has uremic pericarditis) and/or fluid overload [4].

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 [1]. 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 [5]. Moreover, some patients with uremic pericarditis present without symptoms or suggestive findings (chest pain or pericardial rub) on physical examination [6]. Cardiac ultrasonography reveals a pericardial effusion in at least 50 percent of cases.

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jun 09, 2015.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Alpert MA, Ravenscraft MD. Pericardial involvement in end-stage renal disease. Am J Med Sci 2003; 325:228.
  2. Maisch B, Seferović PM, Ristić AD, et al. Guidelines on the diagnosis and management of pericardial diseases executive summary; The Task force on the diagnosis and management of pericardial diseases of the European society of cardiology. Eur Heart J 2004; 25:587.
  3. Rutsky EA, Rostand SG. Treatment of uremic pericarditis and pericardial effusion. Am J Kidney Dis 1987; 10:2.
  4. Lundin AP. Recurrent uremic pericarditis: A marker of inadequate dialysis. Semin Dial 1990; 3:5.
  5. Gunukula SR, Spodick DH. Pericardial disease in renal patients. Semin Nephrol 2001; 21:52.
  6. Banerjee A, Davenport A. Changing patterns of pericardial disease in patients with end-stage renal disease. Hemodial Int 2006; 10:249.
  7. Tarng DC, Huang TP. Uraemic pericarditis: a reversible inflammatory state of resistance to recombinant human erythropoietin in haemodialysis patients. Nephrol Dial Transplant 1997; 12:1051.
  8. Kudo Y, Yamasaki F, Doi T, et al. Clinical significance of low voltage in asymptomatic patients with pericardial effusion free of heart disease. Chest 2003; 124:2064.
  9. Nicholls AJ. Heart and circulation. In: Handbook of Dialysis, Daugirdas JT, Ing TS (Eds), Little, Brown and Co, New York 1994. p.149.
  10. Tseng JR, Lee MJ, Yen KC, et al. Course and outcome of dialysis pericarditis in diabetic patients treated with maintenance hemodialysis. Kidney Blood Press Res 2009; 32:17.
  11. Spector D, Alfred H, Siedlecki M, Briefel G. A controlled study of the effect of indomethacin in uremic pericarditis. Kidney Int 1983; 24:663.
  12. Iyoda M, Ajiro Y, Sato K, et al. A case of refractory uremic pleuropericarditis--successful corticosteroid treatment. Clin Nephrol 2006; 65:290.
  13. Shabetai R. Corticosteroids for recurrent pericarditis: on the road to evidence-based medicine. Circulation 2008; 118:612.
  14. Spaia S, Patsalas S, Agelou A, et al. Managing refractory uraemic pericarditis with colchicine. Nephrol Dial Transplant 2004; 19:2422.
  15. Ifudu O. Daily dialysis in hemodialysis patients with pericardial effusion: where are the data? Int J Artif Organs 1999; 22:469.
  16. Spodick DH. Acute cardiac tamponade. N Engl J Med 2003; 349:684.
  17. Wood JE, Mahnensmith RL. Pericarditis associated with renal failure: evolution and management. Semin Dial 2001; 14:61.
  18. Buselmeier TJ, Davin TD, Simmons RL, et al. Treatment of intractable uremic pericardial effusion. Avoidance of pericardiectomy with local steroid instillation. JAMA 1978; 240:1358.
  19. Nakamoto H, Suzuki T, Sugahara S, et al. Successful use of thoracoscopic pericardiectomy in elderly patients with massive pericardial effusion caused by uremic pericarditis. Am J Kidney Dis 2001; 37:1294.
  20. Zakynthinos E, Theodorakopoulou M, Daniil Z, et al. Hemorrhagic cardiac tamponade in critically ill patients with acute renal failure. Heart Lung 2004; 33:55.
  21. Kleynberg RL, Kleynberg VM, Kleynberg LM, Farahmandian D. Chronic constrictive pericarditis in association with end-stage renal disease. Int J Nephrol 2011; 2011:469602.
  22. Sever MS, Steinmuller DR, Hayes JM, et al. Pericarditis following renal transplantation. Transplantation 1991; 51:1229.
  23. Hastillo A, Thompson JA, Lower RR, et al. Cyclosporine-induced pericardial effusion after cardiac transplantation. Am J Cardiol 1987; 59:1220.
  24. Steele GH, Adamkovic AB, Demopoulos LA, et al. Pericardial effusion coincident with sirolimus therapy: a review of Wyeth's safety database. Transplantation 2008; 85:645.