Pericardial Involvement in ESRD

1
Pericardial Involvement in ESRD

• Trina Banerjee

2
Questions to be Answered

• How Should This Pt. Have Been Treated
• How often should an echo be done
• What is intensive dialysis
• What is better, intensive dialysis or pericardial
  window

3
Outline of Presentation

• Differential of pericardial dz. in Dialysis Pts
• Uremic Pericarditis
• Dialysis Related Pericarditis
• Diagnosis
• Treatment

4
Differential of Pericardial Effusions in Dialysis
Pts

• Uremic Pericarditis/Pericardial Effusion
• Dialysis Related Pericarditis/ Pericardial
  Effusion
• Volume Overload
• Pericarditis for Other Reasons

5
Uremic Pericarditis
6
Definition

• Pericarditis either before or within 8 weeks of
  initiating renal replacement therapy

7
Epidemiology

• 5 of people with advanced acute or chronic renal
  failure
• More common in younger patients
• More common in women

8
Pathophysiology I

• Hypothesis is that the pericarditis arises from
  accumulation of biochemical irritants, but the
  biochemical irritants are unknown
• Calcium alterations, high PTH, and high uric acid
  have at various times been blamed

9
Pathophysiology II

• Immune complex formation may play a role
• Cochran demonstrated impaired fibrinolysis in
  patients predialysis and dialysis patients and
  implicated this as causative
• Abrasion during contractions would extend the
  serositis and could lead to effusion

10
Clinical Presentation

• Pleuritic Pain (32-82 of patients)
• Friction Rub (31-100 of patients)

11
Dialysis Related Pericarditis
12
Definition

• Pericarditis after 8 weeks of renal replacement
  therapy

13
Epidemiology

• More common in younger patients
• More common in women

14
Pathophysiology I

• Uncertain if pathophysiology is the same as in
  uremic pericarditis
• May be secondary to relatively inadequate
  dialysis

15
Pathophysiology II

• Associated with the following
• Inadequate dialysis
• Hypercatabolic conditions
• Hyperparathyroidism
• Infection (especially viral)

16
Clinical Presentation

• Thoracic Pain (41-100)
• Cough or dyspnea (31-57) (93 with tamponade)
• Malaise (54-66)
• Weight Loss (40)
• Fever (75-100)

• Chills (68)
• Friction Rub (59-100)
• Gallop Rhythm (66)
• JVD (68-88)
• Hepatomegaly (68)

17
Diagnosis
18
Diagnosis

• EKG does not show typical ST segment and T wave
  changes
• Echo is used to assess the size of the effusion

19
Treatment
20
Uremic Pericarditis

• If hemodynamically unstable needs surgical
  intervention
• Dialysis with either HD or PD causes rapid
  improvement
• If fails to resolve in 7-10 days needs surgical
  intervention

21
Important Facts about Dialysis

• Resolution rate 76-100
• 15 recurrence rate
• Systemic anticoagulation should be avoided
  because of the high risk of hemorrhage
• Acute fluid removal can lead to cardiovascular
  collapse in tamponade

22
Dialysis Related Pericardial Effusion
23
Treatment Depends on Size

• Large (gt250cc pericardial effusion)
• Drainage
• Medium and Small Effusions
• Intensive Dialysis vs. Drainage

24
Large Effusions
25
Drainage Modality Depends on Hemodynamics

• Acute Tamponade or rapidly accumulating effusion
• Pericardiocentesis
• Stable Large Effusion
• Subxiphoid Pericardiotomy or Pericardiostomy
• Pericardial Window
• Pericardiectomy

26
Pericardiocentesis

• Involves putting a needle into the pericardium
• Recurrence rates as high as 70
• Mortality rate 3-50
• Complications include Mycocardial laceration,
  Coronary artery laceration, and precipitation of
  tamponade

27
(No Transcript)
28
Subxiphoid Pericardiotomy or Pericardiostomy I

• Pericardiotomy is the incision of the pericardium
  
• Pericardiostomy is the installation of a catheter
  after the incision through which steroids are
  infused

29
Subxiphoid Pericardiotomy or Pericardiostomy II

• Performed under local anesthesia
• Intrapericardial catheter can be placed for
  drainage and steroid installation (triamcinolone
  hexacetonide 50 mg q6 for 2-3 days)

30
Rutsky and Rostand

• Looked at 13 patients with dialysis related
  pericardial effusion treated with pericardiostomy
  and steroids
• 100 were effective
• 1 recurrence

31
Pericardial Window

• Either subxiphoid or left thoractotomy approach
• In Subxiphoid a 5cm 2 patch of pericardium is
  resected and a sump drain is attached with
  suction of 10-20mm Hg
• Drain is removed when the output of the tube is
  50-100 mm Hg, usually in 3-4 days
• Left thoracotomy approach is used a variable
  sized window is created and chest tubes are
  inserted, usually for 4-5 days

32
Pericardiectomy

• Performed under general anesthesia
• Thoracotomy Approach

33
Figuera Study I

• 57 ESRD patients with large pericardial effusions
  between 1/1980 and 12/1991
• 5 patients had uremic pericarditis
• 52 patients had dialysis related pericardial
  effusions
• Echo showed more than 300-500 cc of fluid

34
Figuera II

• 7 patients underwent pericardiectomy
• 50 patients underwent subxiphoid pericardial
  window and fluid drainage
• None of the 50 patients who had pericardial
  windows had major surgical complications
• All patients were followed on dialysis
  afterwards and none had recurrence of effusion

35
Small and Medium Effusions
36
Intensive Hemodialysis

• Definition
• Intensive dialysis is considered 4 hours a day
  for 10-14 days (Semin Dial. 1990 32125)
• Problems
• Anticoagulation should not be used
• Hemodynamic shifts may be harmful
• Electrolyte abnormalities

37
Predictors of Poor Response to Intensive
Hemodialysis

• Tgt102
• Systolic BP lt100
• WBCgt15
• JVD, large pericardial effusion, and/or anterior
  and posterior pericardial effusions on the TTE

38
(No Transcript)
39
(No Transcript)
40
Echo Frequency with Intensive Dialysis

• Standard practice is to repeat echo every 3-5
  days during intensive dialysis to assess for
  change in volume

41
Medical Management
42
NSAIDs

• Spektor Trial
• Prospective double blind of 24 patients
• 21 dialysis pericarditis, 3 uremic pericarditis
• No difference in the duration of pleuritic chest
  pain, friction rub, amount of pericardial
  effusion, or need for invasive surgical
  procedures between those treated with
  indomethacin 25mg PO qid and those treated with
  placebo

43
NSAIDs

• Rutsky and Rostand
• Patients with dialysis pericarditis
• 40 Treated with NSAIDs
• 121 not
• No clinical difference

44
Steroids

• Compty
• 8 patients with dialysis pericarditis
• Treated with 20 to 60 mg of prednisone per day
  for 1 to 12 weeks
• 7 of the 8 had their clinical manifestations of
  pericarditis normalize within 1-3 weeks

45
Steroids

• Eliason
• No clinical improvement and increase in infection
  and wound dehiscence after steroids