Uremic Pericarditis

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We are all familiar with “uremic pericarditis” as one of the standard indications for initiating dialysis, and the number of physical exams with a negative cardiac rub I have documented this year is truly impressive.

Which is why, earlier in the year, I was quite surprised when I auscultated a pericarditis rub a few months on a patient who we had just recently initiated on dialysis.

The complication is not seen as much as it used to be, likely because we don’t let patients achieve such an advanced stage of uremia in the modern medical era. This particular patient had some delay in initiating dialysis (she was fairly reluctant to begin and has to be talked into it over a several week-long period following a vascular surgery). She did not have a rub prior to starting dialysis, and our hand-waving theory as to why she didn’t develop a rub until her 3rd or 4th dialysis session was that the partial improvement of her uremic state enabled an inflammatory reaction in the pericardium due to relief of a uremically-suppressed immune system.

Unlike other forms of acute pericarditis, uremic pericarditis classically does not demonstrate diffuse ST-elevations. The condition is treated with frequent dialysis (often daily) or, if tamponade physiology is present (as with our patient) pericardiocentesis may be required. Indomethacin or prednisone may also be employed. Heparin-free dialysis is preferred to avoid hemorrhage into the effusion (which is not altogether uncommon given simultaneous uremic platelet dysfunction).

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