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| {{Pericarditis}} | | __NOTOC__ |
| | {{Uremic pericarditis}} |
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| {{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S. | | {{CMG}}; '''Associate Editor-In-Chief:''' [[Varun Kumar]], M.B.B.S.; [[Lakshmi Gopalakrishnan]], M.B.B.S.{{ADS}}<br> |
| | {{SK}}Pericarditis fibrinosa, Uraemic pericarditis, Pericarditis due to uremia, Pericarditis due to uraemia |
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| ==Overview==
| | '''To go back to the main page on Pericarditis, click [[Pericarditis|here]].''' |
| [[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<ref name="pmid5673609">{{cite journal| author=Bailey GL, Hampers CL, Hager EB, Merrill JP| title=Uremic pericarditis. Clinical features and management. | journal=Circulation | year= 1968 | volume= 38 | issue= 3 | pages= 582-91 | pmid=5673609 | doi= | pmc= | url= }} </ref>.
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| Uremic pericaritis can be further divided as:
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| #Uremic pericarditis in patients not undergoing dialysis.
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| #Uremic pericarditis in patients on maintenance dialysis.
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| ==Etiology== | | ==[[Uremic pericarditis overview|Overview]]== |
| #Absence of [[dialysis]] in renal failure
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| #Inadequate dialysis in renal failure
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| #Volume overload during dialysis
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| #Infections
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| ==Pathophysiology== | | ==[[Uremic pericarditis pathophysiology|Pathophysiology]]== |
| 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.
| | ==[[Uremic pericarditis causes|Causes]]== |
| | ==[[Pericarditis differential diagnosis|Differentiating Uremic Pericarditis from other Diseases]]== |
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| Patients undergoing dialysis may also develop [[pericarditis]]. In a series, 13% of patients undergoing hemodialysis developed pericarditis<ref name="pmid3605080">{{cite journal| author=Rutsky EA, Rostand SG| title=Treatment of uremic pericarditis and pericardial effusion. | journal=Am J Kidney Dis | year= 1987 | volume= 10 | issue= 1 | pages= 2-8 | pmid=3605080 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3605080 }} </ref>
| | ==[[Uremic pericarditis epidemiology and demographics|Epidemiology and Demographics]]== |
| | | ==[[Uremic pericarditis natural history|Natural History, Complications and Prognosis]]== |
| 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]]. | |
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| [[Dialysis]] associated pericarditis may also be secondary to volume overload and bacterial or viral infections<ref name="pmid11172559">{{cite journal| author=Gunukula SR, Spodick DH| title=Pericardial disease in renal patients. | journal=Semin Nephrol | year= 2001 | volume= 21 | issue= 1 | pages= 52-6 | pmid=11172559 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11172559 }} </ref>.
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| Presence of a large pericardial effusion that persists for >10 days after intensive dialysis has a high likelihood of development of [[cardiac tamponade]]
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| ==Diagnosis== | | ==Diagnosis== |
| ===History and symptoms===
| | [[Uremic pericarditis history and symptoms|History and Symptoms]] | [[Uremic pericarditis physical examination|Physical Examination]] | [[Pericarditis laboratory studies|Laboratory Findings]] | [[Uremic pericarditis electrocardiogram|Electrocardiogram]] | [[Uremic pericarditis chest X ray|Chest X ray]] | [[Uremic pericarditis echocardiography|Echocardiography]] | [[Pericarditis CT|CT]] | [[Pericarditis MRI|MRI]] | [[Uremic pericarditis cardiac catheterization|Cardiac Catheterization]] |
| Patients may present with the following symptoms:
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| *[[Fever]]
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| *[[Chest pain]] that improves on leaning forward and worsens on inspiration
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| *[[Breathlessness]]
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| *[[Dizziness]]
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| *[[Malaise]]
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| *[[Ankle edema]]
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| Patients with uremic pericarditis may also present without any symptoms<ref name="pmid16805885">{{cite journal| author=Banerjee A, Davenport A| title=Changing patterns of pericardial disease in patients with end-stage renal disease. | journal=Hemodial Int | year= 2006 | volume= 10 | issue= 3 | pages= 249-55 | pmid=16805885 | doi=10.1111/j.1542-4758.2006.00104.x | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16805885 }} </ref>.
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| ===Physical examination===
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| Patients may present with [[fever]], [[cachexia]] and varying levels of [[consciousness]].
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| '''Vitals:''' [[Hypotension]]and [[pulsus paradoxus]] are present in [[cardiac tamponade]]. The heart rate may be slow due to autonomic impairment or an [[arrhythmia]] such as atrial fibrillation, atrial flutter, heart block or a ventricular arrhythmia may be present due to an [[electrolyte]] imbalance.
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| '''Neck:''' [[Jugular venous distension]] with a prominent Y descent and [[Kussmaul's sign]]
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| '''Chest:''' [[Ewart's sign]] may be present. This includes a pericardial knock, [[pericardial rub]](heard best while leaning forwards) and distant [[heart sounds]]
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| '''Abdomen:''' [[Hepatomegaly]], [[ascites]]
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| '''Extremities:''' [[Ankle edema]]
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| ===Electrocardiogram===
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| Typical [[ECG]] changes of acute pericarditis such as ST and T wave elevations may not be seen in uremic pericarditis. This could be due to non-involvement of myocardium<ref name="pmid11172559">{{cite journal| author=Gunukula SR, Spodick DH| title=Pericardial disease in renal patients. | journal=Semin Nephrol | year= 2001 | volume= 21 | issue= 1 | pages= 52-6 | pmid=11172559 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11172559 }} </ref>.
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| However, [[electrical alternans]] may be seen in presence of [[cardiac tamponade]] and other [[ECG]] changes related to [[electrolyte]]s abnormalities due to poor renal function may be noted.
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| [[Image:Tamponade-with-alternans.jpg|thumb|left|400px|Electrical alternans]]
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| <br clear="left"/>
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| ===Chest X ray===
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| Enlargement of cardiac shadow related to myocardial dysfunction, volume overload, or [[pericardial effusion]] may be observed on chest x-ray.
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| [[Image:Pericardial effusion 4.jpg|thumb|400px|left|Pericardial effusion]]
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| <br clear="left"/>
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| ===Echocardiography===
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| 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.
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| Swinging motion of the heart may be seen in patients with [[cardiac tamponade]].
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| '''Echocardiography of heart with loculated pericardial effusion compressing the left ventricle'''
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| <youtube v=unnmmlCyyZM/>
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| ===Cardiac catheterization===
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| 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.
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| ==Treatment== | | ==Treatment== |
| *Patient with uremic pericarditis should be treated with intensive [[hemodialysis]] which would most often results in resolution of [[pericardial effusion]] and [[chest pain]]<ref name="pmid15120056">{{cite journal| author=Maisch B, Seferović PM, Ristić AD, Erbel R, Rienmüller R, Adler Y et al.| title=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. | journal=Eur Heart J | year= 2004 | volume= 25 | issue= 7 | pages= 587-610 | pmid=15120056 | doi=10.1016/j.ehj.2004.02.002 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15120056 }} </ref><ref name="pmid12923044">{{cite journal| author=Maisch B, Ristić AD| title=Practical aspects of the management of pericardial disease. | journal=Heart | year= 2003 | volume= 89 | issue= 9 | pages= 1096-103 | pmid=12923044 | doi= | pmc=PMC1767862 | url= }} </ref>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]].
| | [[Uremic pericarditis treatment|Overview]] | [[Pericarditis treatment|Medical Therapy]] | [[Pericardiocentesis]] | [[Pericardial window|Pericardial Window]] | [[Pericardiectomy]] |
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| *[[Hypokalemia]] and [[hypophosphatemia]] should be prevented by supplementing the dialysis solution when appropriate<ref name="pmid9725787">{{cite journal| author=Emelife-Obi C, Chow MT, Qamar-Rohail H, Leehey DJ, Gandhi VC, Ing TS| title=Use of a phosphorus-enriched hemodialysate to prevent hypophosphatemia in a patient with renal failure-related pericarditis. | journal=Clin Nephrol | year= 1998 | volume= 50 | issue= 2 | pages= 131-3 | pmid=9725787 | doi= | pmc= | url= }} </ref>.
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| *[[NSAID]]s 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<ref name="pmid11208042">{{cite journal| author=Wood JE, Mahnensmith RL| title=Pericarditis associated with renal failure: evolution and management. | journal=Semin Dial | year= 2001 | volume= 14 | issue= 1 | pages= 61-6 | pmid=11208042 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11208042 }} </ref><ref name="pmid3605080">{{cite journal| author=Rutsky EA, Rostand SG| title=Treatment of uremic pericarditis and pericardial effusion. | journal=Am J Kidney Dis | year= 1987 | volume= 10 | issue= 1 | pages= 2-8 | pmid=3605080 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3605080 }} </ref>.
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| *[[Pericardiectomy]] should be done in refractory and severely symptomatic patients.
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| *Appropriate antivirals or antibiotics should be used in treatment of infective pericarditis which may occur in immunocompromised states resulting after renal transplantation<ref name="pmid1646505">{{cite journal| author=Sever MS, Steinmuller DR, Hayes JM, Streem SB, Novick AC| title=Pericarditis following renal transplantation. | journal=Transplantation | year= 1991 | volume= 51 | issue= 6 | pages= 1229-32 | pmid=1646505 | doi= | pmc= | url= }} </ref>.
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| ==References==
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| {{reflist|2}} | |
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| [[Category:Cardiology]] | | [[Category:Cardiology]] |
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| [[Category:Nephrology]] | | [[Category:Nephrology]] |
| [[Category:Diseases involving the fasciae]] | | [[Category:Diseases involving the fasciae]] |
| | | [[Category:Disease]] |
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| | [[Category:Best pages]] |
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| | [[Category:Up-To-Date]] |
| | [[Category:Up-To-Date cardiology]] |