Case Presentation• F.M s a 67 years old female K/C of :

o HTN

o cerebral aneurysm S/P clipping on 1992.

o CKD Stage 5

• She presented on 21/12 with hypervolemia & hyperuremia symptoms .• Initial labs showed Creatinine of 1010 BUN 40 • Admitted for RRT initiation .• Urgent Femoral cath was done the the day of presentation , and HD was initiated .• AV fistula creation was done on 27/12 • She Received daily HD sessions for almost four days followed by scheduled sessions 3x/week

.

• on Wednesday 4.1.2017 (on the day of the 7th HD session) she developed sever chest pain ( central -left , 9/10 , heaviness ) and SOB.

• Vitally she was stable no drop in the BP ( SBP180-140)• ECG showed ST elevation in multiple leads • Cardiology were contacted : their impression is uremic pericarditis • Echo was done on 10/1 reported small pericardial effusion• She was managed by intensification of HD ( nill heparine ), Aspirin

600mg BID, off prophylactic dose of Heparin.

• On the 2ed day : complete resolution of the chest pain • On 14/1 the pain came back , more sever this time • Vitally she was Desating to 88% on RA.• Spiral CT was done on 15/1 : Segmental & subsegmental PE in the right

upper lobe , with Right cardiac straine.• Therapeutic Heparin infusion was started.• Repeated echo on 23/1 last Tuesday showed moderate pericardial effusion.• Currently she is on Warfarin 3mg & Aspirin 600 mg TID. • Still complaining of chest tightness .

Renal Disease Related Pericarditis

Jawaher Alfaraydi

Objectives1- The anatomy and physiology of the pericardium2- Types of pericarditis 3- Renal disease pericarditis types & definition.4- Epidemiology 5- Pathophysiology 6- Clinical Presentation History And Physical Examination.7- Laboratory findings in uremic pericarditis 8- Medical Management 9- Surgical management10- Complications.

Important Questions To Be Answered• What do we mean by intensive dialysis ?• Is HD better than PD ?• When to consider pericardiocentices ?• How often should an echo be done ?• Aspirin Vs Steroids ?• What about colchicine ?

The Anatomy And Physiology Of The Pericardium

Causes Of Pericarditis

Diagnostic Criteria of Pericarditis 2015 ESC Guidelines for the diagnosis and management of pericardial diseases

Renal Disease Related Pericarditis • The association of pericarditis with kidney disease

was first described in postmortem studies performed in 1836 by Dr. Richard Bright

Type of Pericarditis in Renal Disease 1- Uremic pericarditis.2- Dialysis-associated pericarditis.3-Constrictive pericarditis.

Definitions• Uremic pericarditis :pericarditis that develops before or within 8 weeks of initiation of dialysis.

• Dialysis-associated pericarditis : pericarditis in patients on dialysis for more than 8 weeks.

Why?• The distinction between uremic and dialysis associated pericarditis

first appeared in the literature around the 1970s.

• Pericarditis in dialysis patients appeared to be less responsive to solute clearance with dialysis or intensification of dialysis.

• & they are more likely to have hemorrhagic pericardial fluid, and was more frequently associated with tamponade and hemodynamic instability.

Incidence• The global incidence of pericarditis in uremic patients has declined to

5%∼ in those patients starting dialysis .

• The reported frequency of dialysis pericarditis ranges from 2 to 21%, but recent data are lacking.

Pathology of Renal Disease Related Pericarditis

Pathology• Pericardial fluid is generally exudative with presence of mononuclear

inflammatory cells while histologic evaluation of the pericardium shows predominantly lymphocytic cell infiltration commonly with inflammation extending into the subepicardial myocardium.

Etiology • Uremic pericarditis is thought to be due to accumulation of unidentified uremic toxins

• To date, however, no specific metabolite has been identified as the biochemical culprit. Blood urea nitrogen and serum creatinine levels are similar in uremic patients with and without pericarditis.

• Some evidence suggest that dialysis related pericarditis is similar to uremic pericarditis and likely caused by inadequate dialysis with supporting data demonstrating dialysis noncompliance, decreased flow rates during dialysis, lower clearance (Kt/V), or episodes of access clotting prior to development of pericarditis .

Clinical Presentation

Clinical Presentation • Pleuritic chest pain 50-83%• Friction rub 80-100%• Fevers/chills 30-90%• Dyspnea• Cough• Malaise• Hypotension during dialysis• Signs and symptoms of heart failure

Chest PainSharp pleuritic chest pain (substernal or left parasternal) which is exacerbated with lying flat and improves with sitting forward.

Friction Rub• A superficial scratchy or squeaking sound best heard with the

diaphragm of the stethoscope over the left sternal border • A friction rub is pathognomonic for pericarditis but is present

infrequently and can be transient .

Investigations

ECGIn non-ESRD patients it classically shows• widespread ST segment elevation. • PR segment depression.

• PR segment depression - may be a subtle sign that supports the diagnosis of acute pericarditis. It is not always seen. It may be seen in some leads, but not in others

ECG in Renal Disease Related Pericarditis • However, these classic EKG findings are only found in a minority of

ESRD related pericarditis with most studies in dialysis patients reporting nonspecific EKG changes; only 1–10% having classic ST elevation.

• Due to the lack of the myocardial inflammation.

• If the ECG is typical of acute pericarditis, intercurrent infection must be suspected.

Our Patient ECG

CXR • Cardiomegaly reported in 50–90% of patients.• Pleural effusions are noted in 40–75% of ESRD patients with

pericarditis and are thought to represent a combination of serositis and generalized fluid overload associated with ESRD.

Our Patient CXR

Echocardiography • Small effusions are commonly seen on echocardiograms in the setting

of acute pericarditis.• The incidence of pericardial effusion has been reported to be ~70–

100% in mixed populations of uremic and dialysis-associated pericarditis.

• TTE is also the first test of choice in acute pericarditis.

Labs• leukocytosis (WBC>10,000/mm3) is reported in 40–60% of cases from

a mixed population of uremic and dialysis- associated pericarditis .

• The ESR , CRP are routinely elevated. • Studies have failed to show a significant difference in BUN levels at

the diagnosis time , or an association between decline of BUN levels (after dialysis) and symptom improvement.

The Management

First published: 26 May 2016

Management• Initiation of dialysis if the patient is not on dialysis. • Intensification of dialysis treatment in a patient who is already on

dialysis.• Avoidance of systemic anticoagulation because of increased risk of

bleeding and pericardial drainage in the event of pre-tamponade or tamponade.

Intensive Hemodialysis• Intensive hemodialysis is usually defined as daily hemodialysis for a

period of 10 to 14 days. • The reported efficacy of intensive hemodialysis in the treatment of

uremic pericarditis ranges from 76 to 100% and is >85% in most studies.

• Recurrence occurs in up to 15% of cases.• Intensive hemodialysis is far less effective in treating dialysis

pericarditis than uremic pericarditis. Reported response rates range from 12.5 to 66%, with most <60%.

HD vs PD

Peritoneal Dialysis• There is minimal literature on the use of PD in the treatment of

uremic or dialysis-associated pericarditis. • Patients on PD that developed pericarditis generally underwent

“intensification” of dialysis as did patients on HD.

Three HD patients showed resolution of dialysis-associated pericarditis symptoms after 2–3 sessions of PD before reverting back to HD.

Case 1• 34 YO male on HD • Admitted as a case of infected shunt ( AV Canula ) • Developed pericarditis while on HD • Was managed with daily HD (regional heparinazation)• Developed temponade • Pericardiocentisis done (410cc)• Two days later, temponade reoccur • Decided to use PD for two occasions • Pericardial effusion didn’t reoccur

Medical Management

Medical Management 2015 ESC Guidelines for the diagnosis and management of pericardial diseases

• Aspirin or NSAIDs are mainstays of therapy for acute pericarditis• In cases of incomplete response to aspirin/NSAIDs, corticosteroids may be

used, but they should be added at low to moderate doses to aspirin/NSAIDs.• Although corticosteroids provide rapid control of symptoms, they favour

chronicity, more recurrences and side effects.• The initial dose should be maintained until resolution of symptoms and

normalization of CRP, then tapering should be considered.• Since pericardial effusion is often bloody in uremic patients, anticoagulation

should be carefully considered or avoided in patients starting dialysis.

• Different anti-inflammatory drugs have been proposed

2015 ESC Guidelines For The Diagnosis And Management Of Pericardial Diseases

NSAID/Aspirin

Treatment With Aspirin, NSAID, Corticosteroids, And Colchicine In Acute And Recurrent Pericarditis Massimo Imazio • Yehuda Adle• Aspirin & NSAID are considered mainstay of empiric anti-

inflammatory therapy for pericarditis.• Administration of such drugs should occur every 8 h as attack dose

maintained till symptoms resolution and normalization of markers of inflammation (CRP).

• After the attack dose (1–2 weeks), drug tapering may be considered in order to reduce the subsequent risk of recurrences.

• Aspirin is the first choice for patients who are on aspirin therapy or who need an antiplatelet therapy.

What about Corticosteroids?

Corticosteroids In Non-uremic Pericarditis • Corticosteroids have been often used to treat pericarditis because of

fast symptoms control and the marked reduction in exudative effusions.

• It has been associated with a higher risk of recurrences and prolonged course because of the supposed possible reduction in the infectious agent clearance.

• low to medium doses (i.e., 0.2–0.5 mg/kg/ day) may be a better choice as initial attack doses, as common practice for the treatment of serositis related to systemic inflammatory diseases.

What about steroids in uremic pericarditis ?

Case Report • 66 YO male W/ESRD 2ry to GN• On HD 3/week since 1991 • On July 26 2004 presented with low grade fever & SOB• Dx B/L large pleural effusion & pericardial effusion based on CT • Admitted as a case of uremic pleuralpericarditis based on the analysis of the pleural fluid :hemorrogic

and exudative fluid ( -ve cytology ,BC, and AFB) and pleural biopsy : Diffuse interstitial damage associated with mononuclear cell infiltration.

• Rx with HDF for 4-3/week with pericardiocentisis and thoracocentisis every 2 week for two month without significant improvement

• Then a trial of prednisolone at an initial dose of 50 mg/day tapered to 10 mg/day by 2 months; there after it was maintained at 10 mg/day.

• 6 weeks of corticosteroid therapy resulted in the disappearance of both pleural and pericardial effusions with the reduction in fever. When he was discharged from hospital, he was asymptomatic, his CRP level was < 0.2 mg/dl

Comty et al reported the results of oral glucocorticoid therapy in 8 patients with dialysis pericarditis. Patients received 20 to 60 mg of prednisone per day for 1 to 12 weeks. Clinical manifestations of pericarditis, such as fever, the friction rub, and heart size, improved or normalized in 7 patients within 1 to 3 weeks

• a report by Eliasson et al. failed to confirm clinical improvement and emphasized the potential increase in morbidity (infections, wound dehiscence) after oral glucocorticoid treatment of dialysis-associated pericarditis.

.

Conclusion• Oral glucocorticoid therapy is no longer recommended for uremic or

dialysis pericarditis

Colchicine• Colchicine can be used as part of initial therapy in conjunction with

NSAIDs to reduce the chance of recurrence in non-ESRD related pericarditis.

• However, colchicine has not been studied in uremic or dialysis-associated pericarditis due to the higher risk of toxicity in this population, especially if the dose is not significantly reduced .

Surgical Management

Surgical Interventions • Pericardiocentesis: insertion of a needle into the pericardial sac to aspirate

fluid Effective, but recurrence is common • pericardiostomy and intrapericardial steroids : surgical incision of the

pericardium, usually with installation of a drainage tube, +/- intrapericardial steroids.

• Pericardial window / partial pericardiectomy. Pericardial window generally involves a subxiphoid approach with excision of a portion of the pericardium to allow pericardial fluid to continuously drain into the thoracic cavity. Creation of a larger pericardial window, sometimes via an anterior thoracotomy, is termed partial pericardiectomy.

Pericardiocentesis

• If symptoms did not respond to intensification of dialysis alone (in the absence of tamponade)

• Some series reported high rates of recurrence with pericardiocentesis alone requiring further surgical management.

• Goal : To define patients who will require pericardial drainage.

• Methods : They retrospectively studied risk factors for pericardial drainage in patients admitted with pericardial effusion and chronic renal failure.

Results• Between 2000 and 2012, 44 Patients with Uremic pericardial effusion (UPE) were identified • 43 % HD, 7 % PD , 11 % KT , 39 % had CKD 4 or 5. • Cause of UPE was uremic pericarditis in 45.5 %, dialysis pericarditis in 45.5 %, and other in 9 %.• On initial echocardiography, UPE was estimated small in 38 %, moderate in 32 %, and large in

30 %. • Tamponade signs were observed in 16 % of patients. • During follow-up, 100 % of large effusions required drainage (70 % immediate, 30 % delayed). • For moderate and small UPE, the initial size on echocardiography was not discriminating.• For moderate and small UPE, Serum albumin level was highly predictive of the risk of

drainage: when albuminemia was <31 g/l, 35 % patients were drained vs. only 7 % when albuminemia was >31 g/l.

Conclusion• In this first study reporting UPE drainage risk factors, all large UPE

required drainage even when extrarenal epuration intensification or medical treatment were tried. This suggests that large UPE should be drained without delay.

• For small and moderate UPE, size of effusion on echocardiography does not predict drainage requirement but serum albumin level does.

Complications

TamponadeSymptoms :vague complaints and appear faint and weakOn Examination : Hypotension and tachycardia Decreased heart sounds Jugular venous distention.Diagnosis can be supported by presence of a pulsus paradoxus or electrical alternans on EKG. However, it can have subtle presentations, from a large amount of fluid accumulating slowly over time .

References • https://academic.oup.com/eurheartj/article/36/42/2921/2293375/2015-ESC-Guidelines-for-the-diagnosis-and• http://www.sciencedirect.com/science/article/pii/0002934384907423• https://www.ncbi.nlm.nih.gov/pubmed/22661042• http://onlinelibrary.wiley.com/doi/10.1111/sdi.12517/full• https://www.ncbi.nlm.nih.gov/pubmed/?term=A+case+of+refractory+uremic+pleuropericarditis--successful+cortic

osteroid+treatment• http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/585899• https://www.ncbi.nlm.nih.gov/pubmed/12695728 • https://www.ncbi.nlm.nih.gov/pubmed/?term=Pericarditis+in+uremic+patients%3A+serum+albumin+and+size+of

+pericardial+effusion+predict+drainage+necessity

• https://www.uptodate.com/contents/aspirin-drug-information?source=preview&search=Asprin&anchor=F137098#F137098

• https://www.uptodate.com/contents/pericarditis-in-renal-failure?source=search_result&search=uremic%20pericarditis&selectedTitle=1~17

• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1930318/• https://www.ncbi.nlm.nih.gov/pubmed/25796283• https://www.ncbi.nlm.nih.gov/pubmed/5558645

Thank you