1. Pericardial disease in ESRD patients 신장내과 R2 최경진

2. Differential of pericardial disease  Pericardial involvement in end-stage renal disease (ESRD) is manifested most commonly as acute uremic or dialysis pericarditis and infrequently as chronic constrictive pericarditis.  Uremic pericarditis  Dialysis-associated pericarditis  Constrictive pericarditis  Asymptomatic pericardial effusion

3. Uremic pericarditis  Definition  Pericarditis that develops before or within 8 weeks of initiation of dialysis  5% of people with advanced acute or chronic renal failure  More common in younger patients & women  Hypothesis is that the pericarditis arises from accumulation of biochemical irritants, but the biochemical irritants are unknown  Clinical presentations  Pleuritic Pain (32-82% of patients)  Friction Rub (31-100% of patients)

4. Dialysis associated pericarditis  Definition  Pericarditis in patients on dialysis for more than 8 weeks  More common in younger patients & women  Pathophysiology  Uncertain if pathophysiology is the same as in uremic pericarditis  May be secondary to relatively inadequate dialysis Dialysis noncompliance, Decreased flow rates during dialysis, Lower clearance (Kt/V) & Episodes of access clotting prior to development of pericarditis  Associated with the following:  Hypercatabolic conditions  Hyperparathyroidism  Infection (especially viral)

5. Dialysis associated pericarditis  Pericarditis can present differently in ESRD patients. Accompanying symptoms often include fever, chills, dyspnea, cough, and malaise.

6. Diagnosis – EKG & Imaging  ECG in a pericardial effusion  Sinus tachycardia  Low QRS voltage  Electrical alternans  Chest x-ray  In the non-ESRD population, CXR findings are generally normal in pericarditis unless there is concomitant viral, bacterial, or mycobacterial pneumonia or presence of malignancy  However, in ESRD patients with uremic or dialysis-associated pericarditis, Abnormalities on CXR with cardiomegaly reported in 50-90% of patients

7. Pericardial effusion definition  Echocardiography is used frequently  e.g) pericardial effusion, associated myocarditis with alteration in ventricular function, or constriction  The incidence of pericardial effusion has been reported to be 70-100%  Small effusion  < 50-100 ml  Echo-free space in the pericardial sac was < 10mm  Moderate effusion  Between 100 and 500 ml  Echo-free space was between 10 and 20 mm  Large effusion  > 500 ml  Echo-free space was >20 mm

8. Laboratory studies  Leukocytosis and elevated inflammatory markers (ESR, CRP)  In ESRD patients  Leukocytosis is reported in 40-60% of cases  Studies have failed to show the result  a significant difference in the BUN levels in patients with or without dialysis- associated or uremic associated pericarditis at diagnosis  an association between decline of BUN levels (after dialysis) and symptom improvement

9. Management – Uremic pericarditis  Initiation of dialysis  Symptom resolution  Resolution of pericardial effusion  Improvement in survival  Development of uremic pericarditis is an absolute indication for initiation of RRT  Resolution rate 76-100%  15% recurrence rate  Recommend use of heparin-free  because of the high risk of hemorrhage

10. Management – Dialysis-associated pericarditis 1) Intensification of Dialysis  50-70% of pericarditis and pericardial effusions resolving with dialysis alone  In the presence of a pericardial effusion, intensification of dialysis may increase the risk hypotension from ventricular collapse due to aggressive volume removal  Under-dialysis before the onset of pericarditis  Low Kt/V  Missed treatments  Shortened treatments

11. Intensive hemodialysis ?  Frequency ? Duration ?  Intensive dialysis is considered 4 hours daily for 10-14 days (Semin Dial. 1990; 3:21–25)  Problems  Anticoagulation should not be used  Hemodynamic shifts & Electrolyte abnormalities  The “intensified” dialysis continue until symptoms resolve, until the effusion disappears or for some period after resolution  Echo frequency with intensive dialysis  Every 3-5 days during intensive dialysis to assess for change in volume

12. Management – Dialysis-associated pericarditis 2) Medical management  Severe studies have evaluated medical management of pericarditis with NSAID medications, steroids, and colchicine.  Steroids  No clinical improvement and increase in infection  Wound dehiscence after steroids  Treating uremic or dialysis-associated pericarditis with steroids is minimal with studies  Colchicine  Not been studied in uremic or dialysis-associated pericarditis

14. [Case report, 67/F] Refractory uremic pleuropericarditis treated successfully with corticosteroid therapy  67/F on HD (10yrs) with recurrent dyspnea lasting for 2 weeks  Diagnosed with uremic pleuropericarditis  Intensive hemodialysis (high-flux dialyser, for 4hr four times a week, no heparin use)  Administration of antibiotics and NSAIDs  Repeated thoracentesis and pericardiocentesis  Pleural biopsy: thick fibrinous pleuritis without infection or malignancy

15. [Case report, 67/F] Refractory uremic pleuropericarditis treated successfully with corticosteroid therapy

17. Management – Dialysis-associated pericarditis 3) Surgical management  Due to the lack of trials, there is considerable debate

18. Management – Dialysis-associated pericarditis  Pericardiocentesis  Involves putting a needle into the pericardium  Recurrence rates as high as 70%  Mortality rate 3-50%  Complication include myocardial laceration, coronary artery laceration and precipitation of tamponade

19. Management – Dialysis-associated pericarditis  Pericardiostomy and intrapericardial steroids  Pericardiotomy is the incision of the pericardium  Pericardiostomy is the installation of a catheter after the incision through which steroids are infused  Pericarditis in end-stage renal disease Cardiol Clin. 1990Cardiol Clin.  Looked at 13 patients with dialysis related pericardial effusion treated with pericardiostomy and steroids  100% were effective & 1 recurrence  Pericardial window/partial pericardiectomy

22.  Immediate drainage was required for 20% of patients, delayed drainage for 25%, and no drainage for 55%  The 35 patients with delayed or no drainage had intensification of extra-renal epuration in 60% of cased (n=21), medical treatment in 14% (n=5), and no treatment in 26% (n=9)

23.  All patients with a pericardial effusion > 500 ml were drained, most of them immediately. The patients who were not drained immedicately underwent drainage during follow-up with variable time lags.  This study is reporting hypoalbuminemia as a risk factor for pericardial drainage in small or moderate UPE  Serum albumin is an important predictive factor for drainage

24.  For small and moderate UPE, size of effusion on echocardiography does not predict drainage requirement but serum albumin level does  Hypoalbuminemic patients below 31 g/L must be carefully followed up

25. Asymptomatic pericardial effusion  It is hard to differentiate truly asymptomatic effusions from those accompanying pericarditis.  Management of such asymptomatic pericardial effusion remains controversial  In the absence of inflammation or serositis, medical therapies are not efficacious and pericardiocentesis can result in frequent recurrences

26. References  Pericarditis and Pericardial Effusions in End-Stage Renal Disease Division of Nephrology  Refractory uraemic pleuropericarditis treated successfully with corticosteroid therapy NDT Plus (2009) 2: 473–475  Pericarditis in uremic patients: serum albumin and size of pericardial effusion predict drainage necessity J Nephrol (2015) 28:97–104