Article, Cardiology

Uremic pericarditis in patients with End Stage Renal Disease: Prevalence, symptoms and outcome in 2017

a b s t r a c t

The prevalence of uremic pericarditis (UP) used to range from 3% to 41%. More recently, it has decreased to about 5%-20% and to b 5% in the last decades, as hemoDialysis techniques have become widely used and dialysis quality improved. The objective of this work is to determine the initial clinical picture and the prognosis of patients pre- senting end stage renal disease (ESRD) with UP. Materials: This is a retrospective study (May 2015-September 2017). Inclusion criteria targeted patients who had uremic pericarditis defined as pericarditis occurring in a pa- tient with ESRD before initiation of renal replacement therapy, or within eight weeks of its initiation. Results: 16 patients met the inclusion criteria. The median age of patients was 54 [24, 71] years and 56.2% were male. Peri- cardial effusion was small, moderate and large in 31.2%, 37.6% and 31.2% of cases respectively. One pericardiocentesis was performed in view of a clinical picture of impending cardiac tamponade and three pericar- dial drainages were performed given presentation of tamponade. Hemodialysis was initiated for all the patients and continued for 2 to 3 weeks until complete regression of the pericardial effusion. The mean number of dialysis sessions was 11 +- 3.5. One patient died of septic shock that developed three weeks after diagnosis of uremic peri- carditis. Conclusion: UP is considered a rare but fatal complication of ESRD because of the risk of tamponade and its prognosis remains dependent on early diagnosis and adequate treatment of ESRD.

(C) 2017

Materials and methods

Uremic pericarditis (UP) and dialysis pericarditis constitute the most common pericardial diseases in end-stage renal disease . The first cases of uremic pericarditis (UP) were reported in postmortem studies by Richard Bright in 1836 and several studies were published between 1970 and 1990. Since 1990, there have been very few, as he- modialysis techniques have become widely used and the quality of dial- ysis has improved [1-4]. The prevalence of uremic pericarditis (UP) used to range from 3% to 41%; more recently, it decreased to about 5%-20% and in past decades, to b 5% [1-6]. Certainly, this is still a low percentage, but considerable relative to the increasingly large number of patients in ESRD. Why do certain patients develop UP and not others: are there risk factors and/or specific triggering factors, and what is the prognosis for UP in 2017? The aim of this study was to determine the initial clinical picture and the prognosis of patients presenting End Stage Renal Dis- ease with UP.

* Corresponding author at: Avenue Hassan II, rue Kadissia, numero 12, Oujda, Morocco.

E-mail address: [email protected] (Y. Bentata).

We conducted a retrospective study for 28 months (May 2015 to September 2017) at the kidney dialysis unit of Mohammed VI Universi- ty Hospital, Oujda, located in Eastern Morocco, North Africa. Included were all patients diagnosed with uremic pericarditis. Uremic pericardi- tis was defined as pericarditis occurring in a patient with ESRD before initiation of renal replacement therapy, or within eight weeks of its ini- tiation [3,7]. The diagnosis of UP was based on the presence of chest pain and/or pericardial friction rub and pericardial effusion objectified at echocardiography. Excluded were patients who had dialysis pericarditis (8 weeks after initiation of renal replacement therapy), patients who had ESRD with any other pericarditis etiologies such as viral infection, tuberculosis, Nephrotic syndrome, cirrhosis, cardiac insufficiency and patients who had acute kidney injury.

Results

Out of 937 patients who started hemodialysis in the Nephrology De- partment for severe chronic kidney disease during the period of study and who have had echocardiography, 16 patients had uremic pericardi- tis or a prevalence of 1.7%. All patients had UP that occurred before ini- tiation of renal replacement therapy. Of the 16 patients, six of them

https://doi.org/10.1016/j.ajem.2017.11.048

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Y. Bentata et al. / American Journal of Emergency Medicine 36 (2018) 464466 465

were aged b 30 years and seven were aged N 65 years. One patient was of Black race. 75% had not previously undergone regular nephrology follow-up. We had to perform one pericardiocentesis faced with a clin- ical picture of impending cardiac tamponade, and three Pericardial drainages faced with presentation of tamponade. One emergency peri- cardial drainage was performed on admission of the patient to the hos- pital. The two others were performed with pericardial windows, following an aggravation of the pericardial effusion and clinical symp- tomatology a few days after hospital admission of the two patients. The pericardial effusion was hemorrhagic in the four patients who underwent the pericardiocentesis and pericardial drainage. Hemodialy- sis was initiated in all these patients and continued for 2 to 3 weeks until complete regression of the pericardial effusion. The mean number of di- alysis sessions was 11 +- 3.5. The blood culture was negative in all pa- tients at the time of UP diagnosis and no patient was HIV positive. Among the 16 patients, 15 had a favorable evolution with complete re- gression of the pericardial effusion and one patient died of septic shock that developed three weeks after diagnosis of uremic pericarditis, al- though evolution of the UP was favorable. Table 1 shows the clinical, bi- ological and echocardiographic parameters of patients admitted for ESRD with uremic pericarditis.

Table 1

Clinical, biological and echocardiographic parameters of patients admitted for ESRD with uremic pericarditis.

Discussion

Very few series on UP have been published over the last thirty years and the majority of them combine UP and pericarditis dialysis without presenting the distinctive clinical, biological and echocardiographic characteristics of the two pathologies. The series published by Sadjadi et al. and Bataille et al. comprise the two major series of these last three decades on pericarditis with ESRD. 30 cases were identified in 30 years in the Sadjadi et al. series and 44 cases were identified in 12 years in the series of Bataille et al. [6,8]. Only half of these reported cases were cases of UP, making its prevalence even lower with an inci- dence of 1 to 2 cases per year. In our study, 16 cases were identified in less than three years with a prevalence of 1.7%. This relatively high prev- alence is largely explained by the delayed diagnosis of chronic kidney disease, as shown by the absence of nephrology follow-up in two thirds of the patients and by the difficulty of diagnosing UP due to its silent and non-specific nature, particularly among the population of patients with ESRD. For UP, some risk factors have been raised by some authors and not retained by others, such as male sex, advanced age, diabetes, sys- temic infection, acidosis, serum albumin and phosphocalcic disorders [6,8,9]. These factors might act through different toxic, inflammatory, metabolic, immunologic and infectious mechanisms and would lead to an increase in the permeability of the pericardium. The physiopathology of UP remains incompletely elucidated but uremic toxins seen to play a major role in its physiopathology [10,11]. Male sex was reported in 93% and 57% respectively in the series of Sadjadi et al. and Bataille et al. [6,8]. The prevalence of diabetes was 14% and 16% respectively in the two se- ries of Bataille et al. and El-Said et al. [8,9]. Pericardial tamponade re- mains a deadly and feared complication of pericarditis with

accompanying pericardial effusion and the prevalence of pre-

Parameters (n = 16) N (%)

Age, yearsa 54 [24, 71]

Male gender 8 (56.2)

Body mass index, kg/m2b 23.82 +- 0.09

Etiology of nephropathy

Type 2 diabetes 6 (37.5)

Nephrosclerosis 3 (18.7)

Glomerulopathy 2 (12.5)

Uropathy 1 (6.2)

Undetermined 4 (25)

Dyspnea 10 (62.5)

Chest pain 7 (43.7)

Systolic blood pressure, mm Hgb 143 +- 26

Diastolic blood pressure, mm Hgb 77 +- 11

Pericardial friction rub 5 (31.2)

Uremia encephalopathy 3 (18.8)

Oligoanuria (b500 ml/day) 7 (43.7)

Blood creatinine umol/lb 1038 +- 287

Blood urea, mmol/lb 45.8 +- 10.1

Blood calcium, mmol/lb 1.81 +- 0.35

blood pHosphorous mmol/lb 2.46 +- 0.96

Blood parathormon, pg/mla 185 [124, 346] Acidosis

Blood bicarbonates b 20 mmol/l 15 (93.7)

Blood bicarbonates b 15 mmol/l 11 (68.7)

Hemoglobin, g/dlb 7.8 +- 1.8

Serum albumin, g/lb 28.5 +- 7.6

C-reactive protein, mg/la 54 [11, 126]

Pericardial effusion 16 (100)

Pericardial effusion

Small: b10 mm 5 (31.2)

Moderate: 10-20 mm 6 (37.6)

Large: N 20 mm 5 (31.2)

Cardiac tamponade 3 (18.7)

Dialysis initiation 16 (100)

Central venous catheter 15 (93.7)

Blood transfusion 11 (68.7)

Pericardiocentesis 1 (6.2)

Pericardial drainage 3 (18.7)

Drainage with pericardial window 2 (12.5)

Overall in-hospital mortality or at 30 days 1 (6.2)

a Variables expressed as median, interquartiles.

b Variables expressed as mean and SD.

tamponade and tamponade was 10% to 35% and the reported mortality was 0% to 10%, depending on the series [4,6,8]. The treatment of uremic pericarditis is based on initiation of dialysis if the patient is not under treatment and intensification of dialysis treatment in a patient who is already on dialysis. The avoidance of systemic anticoagulation is impor- tant because of increased risk of bleeding and pericardial drainage in the event of pre-tamponade or tamponade [12]. The use of anti- inflammatory drugs such as indomethacin and colchicine is not very recommended in the context of ESRD and does not seem to influence the evolution of UP.

Conclusion

Uremic pericarditis is currently considered to be a rare but serious pathology of ESRD and the absence of clinical symptomatology leads to underestimation of its real prevalence. A good prognosis is dependent on early diagnosis, emergency initiation of hemodialysis, avoidance of anticoagulation and the establishment of strict cardiorenal monitoring.

Disclosure statement

The authors declare that they have no conflicts of interest.

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