Uremic pericarditis N18.89+I32.8*

Uremic pericarditis was first described in 1836 by Richard Bright (Bright 1836).

Uremic pericarditis is a complication of uremia that leads to a metabolic inflammation of the pericardium. The inflammation can lead to an accumulation of fluid between the two pericardial sheets. Uremic pericarditis always represents an acute emergency situation (Keller 2010 / Kaufmann 2015 / Pinger 2019).

One differentiates between a:

1. uremic pericarditis: this occurs in the pre-dialytic phase or 8 weeks after starting dialysis therapy
2. dialysis-associated pericarditis: the 2nd form manifests itself > 8 weeks after the start of dialysis treatment (Kuhlmann 2015).

We also distinguished between a:

• Pericarditis with pericardial tamponade (this occurred in 16 % of 44 patients in a study)
• Pericarditis without pericardial tamponade (Kuhlmann 2015)

Uremic pericarditis can occur in the context of:

• acute renal insufficiency
• chronic renal insufficiency
• insufficient dialysis treatment (Keller 2010)

Since nowadays, early dialysis is usually sought, uremic pericarditis is now rarely seen. When it occurs, it almost always occurs in the context of a too low dose of dialysis (Kasper 2015).

In addition, pericarditis in uremic patients can occur in the context of concomitant diseases such as:

• sepsis
• Virus infections
• systemic diseases such as systemic lupus erythematosus (SLE) (Kuhlmann 2015)

The cause of uremic pericarditis is always the presence of a final stage uremia. Risk factors are:

• Overhydration
• Hypalbuminemia
• insufficient dialysis dose (Kuhlmann 2015)

Pathophysiologically, the accumulation of uremic toxins leads to a metabolic inflammation of the pericardium (Fölsch 2000).

Uremic pericarditis occurs in about 10 % - 20 % of all dialysis patients (Kuhlmann 2015).

Uremic pericarditis - in contrast to other pericarditis - often remains symptomless. In the remaining cases the symptoms usually develop slowly. They can then persist:

• respiratory pericardial pain (Kasper 2015)
• subfebrile temperatures or fever (Kuhlmann 2015)

Auscultation

• Frictional noise of the pericardium (comparable to the noise when forming a snowball (Geberth 2011)

ECG

• shortened PQ- time
• diffuse ST- elevations (can be missing especially in uremic P. but also in uremic P. (Keller 2010; Kasper 2015)

X-ray thorax

On chest X-ray, very large pericardial effusions can be seen as a widening of the cardiac silhouette (Kuhlmann 2015).

Echocardiography

• Pericardial effusion

An effusion is not mandatory, but if present, even a small effusion of 15 ml or more can be detected by echocardiography. Often, the effusion is bloody [Adler 2017].

• Pericardial tamponade (rarely occurring) (Kasper 2015).

Leukocytosis (Kuhlmann 2015)

Pericardial tamponade for large pericardial effusion

Gluing of the two pericardial leaves with impairment of cardiac pumping performance and possibly uncontrollable right heart failure (Geberth 2011; Keller 2010)

The occurrence of uremic pericarditis is an urgent indication for immediate dialysis in pre-dialysis patients (recommendation level IIa, evidence level C). However, anticoagulation should be avoided because of the often bloody pericardial effusion.

The occurrence of uremic pericarditis in patients who have already been dialyzed should lead to an intensification of dialysis (recommendation level IIa, evidence level C) (Adler 2017).

If the dialysis treatment fails:

• a pericardiocentesis can be considered (recommendation level IIb, evidence level C)
• pericardial drainage is particularly indicated in the case of recurrent effusions (Kasper 2015)
• if necessary, drug treatment with NSAIDs and corticosteroids (systemic or intrapericardial) may be considered (recommendation level IIb, evidence level C) (Adler 2017)

If haemodynamically intolerable adhesion of the pericardial leaves occurs, a pericardiotomy may (in rare cases) become necessary (Geberth 2011).

If pericardial tamponade occurs even less frequently, pericardiocentesis or cardiac surgery is indicated (recommendation grade I, evidence grade C) (Adler 2017).

The pericardial effusion usually disappears after 1 - 2 weeks with the appropriate treatment. If this is not the case, a pericardiocentesis is recommended if haemodynamically effective (Geberth 2011).

1. Adler Y et al. (2017) ESC Pocket Guidelines of the ESC (European Society of Cardiology) and DGK (German Society of Cardiology.Börm Bruckmeier Verlag
2. Bright R (1836) Cases and observations, illustrative of renal disease accompanied with the secretion of albuminous urine. OCLC number: 40765372 Guy's Hospital Reports (1, No 2) 338 - 379
3. Fölsch U R et al (2000) Pathophysiology. Springer Publishing House 230
4. Geberth S et al (2011) Practice of dialysis according to the guidelines NKF KDOQITM, KDIGO, EDTA, DGfN. Springer publishing house 13, 147 - 148
5. Herold G et al (2020) Internal medicine. Herold Publishing House 642
6. Kasper D L et al (2015) Harrison's Principles of Internal Medicine. Mc Graw Hill Education 1817 - 1818
7. Kasper D L et al (2015) Harrison's Internal Medicine. Georg Thieme Publisher 2232
8. Keller C K et al (2010) Practice of nephrology. Springer Publishing House 209
9. Kuhlmann U et al (2015) Nephrology: Pathophysiology - Clinic - Kidney replacement procedure. Thieme Publishing House 432, 696
10. Pinger S et al (2019) Repetitorium Kardiologie: For clinic, practice, specialist examination. German Medical Publisher 590 - 593