Kidney Case Conference:
How I Treat
Management of Patients with Kidney
Failure and Pericarditis
Raphael J. Rosen and Anthony M. Valeri
CJASN 18: 270–272, 2023. doi: https://doi.org/10.2215/CJN.07470622
Introduction
Diseases of the pericardium, including pericarditis,
pericardial effusion, and tamponade, are common in
patients with kidney failure, but there are limited
data to guide management. We present a clinical case
and our approach to managing these challenging
clinical situations.
Case
A 23-year-old woman with hypertension and
kidney failure on dialysis via arteriovenous fistula
was admitted with fever and chest pain. Her kidney
disease was attributed to childhood-onset hyperten-
sion, and she did not have lupus or another auto-
immune disease. She had poor adherence to dialysis
and often missed four or five sessions in a row. She
was febrile and hypertensive to 240/140 and had
signs of underdialysis, including a creatinine of 15
mg/dl, BUN of 81 mg/dl, potassium of 5.8 mEq/L,
and phosphate of 8.5 mg/dl. A pericardial rub was
appreciated. Echocardiogram demonstrated a large
circumferential pericardial effusion with systolic
right atrial collapse.
Diagnosing Tamponade
The first question that must be addressed is
whether this patient has cardiac tamponade. Physical
examination findings of tamponade include tachy-
cardia, hypotension, distended jugular veins, distant
heart sounds, and pulsus paradoxus. Echocardio-
graphic features typically include a large pericardial
effusion, plethoric inferior vena cava, and signs of
increased pericardial pressure, such as systolic atrial
and diastolic ventricular collapse. Pulsus paradoxus
(an exaggerated decrease in systolic BP during in-
spiration) and its echocardiographic equivalent, in-
creased respirophasic variation of mitral valve
inflow, can also suggest tamponade (1). Tamponade
is an emergency and requires immediate pericardial
drainage. In this patient’s case, although echocardio-
graphic findings of high pericardial pressure were
present, the patient did not clinically have tampo-
nade. Invasive management was deferred in favor of
dialytic management.
270 Copyright © 2022 by the American Society of Nephrology
Division of
Uremic Pericarditis versus Dialysis-Associated Nephrology,
Department of
Pericarditis
Medicine, Columbia
The patient had chest pain, fever, and a pericardial University Vagelos
rub and was diagnosed with pericarditis. Pericarditis College of Physicians
has long been recognized as part of the uremic syn- and Surgeons, New
drome. As dialysis became more available in the United York, New York
States, the prevalence of pericarditis declined but was
still observed, even in well-dialyzed patients. This led to Correspondence:
Dr. Raphael J. Rosen,
the recognition of a separate entity from uremic peri- 292 Long Ridge Road,
carditis, referred to as dialysis-associated pericarditis, Suite 203, Stamford,
diagnosed in patients who develop pericarditis after CT 06902. Email:
being on dialysis for at least 8 weeks (2). Others have rrosen3@stamhealth.
org
questioned whether dialysis-associated pericarditis is, in
fact, a separate entity from uremic pericarditis, noting
that patients on dialysis who develop pericarditis often
have a preceding period of underdialysis or missed
sessions before symptoms develop (3,4), as was the case
in our patient. The incidence of uremic pericarditis has
declined to 5%, and the incidence of dialysis-associated
pericarditis ranges from 2% to 21%, although recent
data are lacking (1). Pericarditis occurs more commonly
in younger individuals and more commonly in women
than men (2).
Alternative Etiologies
Patients with kidney failure may also develop peri-
carditis from causes that affect the general population as
well, such as malignancy, infection (viral, bacterial, or
tuberculosis), and trauma. There are other etiologies of
pericarditis that are probably more prevalent in patients
with kidney failure than the general population, such as
myocardial infarction, autoimmune disease (i.e., patients
with kidney failure from lupus), use of certain medica-
tions (i.e., the use of hydralazine in patients with reduced
GFR), and, rarely, direct perforation from dialysis
catheter migration. If, after careful history and physical
examination, no alternative etiology is apparent in a
patient with kidney failure and pericardial disease, then
the etiology can be presumed to be due to kidney failure.
Dialytic Management of Patients with Kidney
Failure and Pericarditis
Intensity of Dialysis
Patients with uremic pericarditis respond rapidly to
the initiation of dialysis, whereas dialysis-associated
www.cjasn.org Vol 18 February, 2023
CJASN 18: 270–272, February, 2023
pericarditis has a much lower likelihood of responding to
dialysis intensification (5). In the largest series of patients
with kidney failure and pericarditis, those with uremic
pericarditis had an 85% likelihood of responding to
dialysis initiation, and those with dialysis-associated
pericarditis had a 56% likelihood of improving with
dialysis intensification (4). Given that many cases of
dialysis-associated pericarditis may have a uremic con-
tribution (i.e., a period of underdialysis or increased
catabolism) and the low likelihood for harm from extra
dialysis sessions, an intensified dialysis regimen, termed
“superdialysis” by some (6), is recommended in cases of
dialysis-associated pericarditis (1).
Our regimen for intensified dialysis is 4 hours of dialysis
daily (or six times per week) for 7–14 days with limited
echocardiography performed every 3 days to monitor for
changes in the size of pericardial effusion and close
monitoring of patient symptoms (2,4).
Other Dialysis Considerations
With more intensified dialysis, the use of a higher
potassium bath may be required to prevent hypokalemia.
In patients who have not missed hemodialysis sessions and
develop pericarditis, we recommend checking the Kt/V to
ensure that their routine dialysis is achieving adequacy.
Because heparin exposure and pericardial hemorrhage
have been proposed as contributors to dialysis-associated
pericarditis, we use heparin-free dialysis or regional anti-
coagulation (if available) (1).
In cases of increased pericardial pressure, lower
ultrafiltration rates should be used. Faster ultrafiltration
rates can cause intradialytic hypotension even in stable
patients on dialysis, and in the setting of increased
pericardial pressure can cause transient intravascular
volume depletion, precipitating tamponade physiology
(7). Because of the increased frequency of dialysis, less
ultrafiltration is required per treatment to maintain
fluid balance.
Pharmacologic Interventions for Pericarditis in
Kidney Failure
In a small randomized controlled trial, nonsteroidal
anti-inflammatory drugs (NSAIDs) were found to im-
prove fever but not chest pain, pericardial rub, or the size
of pericardial effusion (6). Potential drawbacks of NSAIDs
include worsening of residual kidney function and pre-
cipitating pericardial hemorrhage. Systemic steroids are
effective in resolving pericardial symptoms but were
found in early reports to result in increased serious
infections (8). There are scant reports of colchicine use
in patients with kidney failure and pericarditis, and there
is significant risk of toxicity (1). We do not use NSAIDs,
steroids, or colchicine in patients with kidney failure and
pericarditis, focusing instead on optimizing dia-
lytic therapy.
Invasive Management of Pericardial Effusion in
Kidney Failure
The decision about when to pursue invasive drainage of
pericardial effusion versus continuing conservative/dialytic
Kidney Failure and Pericarditis, Rosen and Valeri 271
management is a challenging one. This decision should be
made jointly by the treating cardiologist and the nephrol-
ogist, and it depends on patient trajectory, serial echocar-
diography, and local expertise. Surgical window was
previously favored as the initial treatment over percuta-
neous pericardiocentesis due to a high rate of recurrence
after pericardiocentesis (in one large series, 70% recur-
rence) (7). In more recent years, pericardiocentesis with
drain placement has become more common as initial
therapy, with surgical management with pericardial win-
dow reserved for recurrent effusions or cases requiring
pericardial biopsy. Excessive recurrence is not seen in the
modern era, likely due to improved clearance with current
dialytic methods. In a recent series, in 11 patients with
dialysis-associated pericarditis treated with percutaneous
drainage, no recurrences were noted at a mean follow-up
of 18 months (9).
In a recent retrospective series of patients with kidney
failure and pericarditis, risk factors that predicted requiring
pericardial drainage included large size of pericardial
effusion and hypoalbuminemia. All patients with a large
pericardial effusion in this series required pericardial
drainage (10).
In the setting of a large effusion that is asymptomatic,
we pursue an initial trial of intensive dialysis if the cause
is uremic pericarditis or if it is dialysis-associated
pericarditis that was triggered by a period of under-
dialysis (which may be more likely to respond to dialytic
therapy, akin to a true uremic pericarditis). In a well-
dialyzed patient with dialysis-associated pericarditis
with a large effusion, we recommend immediate
drainage (8).
Our approach to patients with kidney failure and
pericarditis is outlined in Figure 1.
Pericardial Fluid Analysis
When drainage is performed, the fluid should be sent for
cell count and differential; gram and acid-fast stain;
bacterial, mycobacterial, and fungal culture; adenosine
deaminase; PCR for tuberculosis; and cytology (1). In case
series of patients with kidney failure and pericardial
effusion, pericardial fluid was usually serosanguinous
with mononuclear predominance (2). There is no specific
pericardial test that definitively demonstrates that a peri-
cardial effusion was caused by uremia, and pericardial
fluid analysis is most useful for ruling out alterna-
tive etiologies.
Case Conclusion
Our patient had a clear period of underdialysis as her
likely trigger for pericarditis. Given that some dialysis-
associated pericarditis responds to dialysis intensifica-
tion and that she might have a component of uremia
contributing, the decision was made to proceed with
intensified dialysis. After 10 days of intensive dialysis,
serial echocardiography demonstrated increasing size of
pericardial effusion, and she underwent pericardiocent-
esis with drainage of 800 ml of fluid, with immediate
improvement of her symptoms. By hospital discharge,
the effusion had not reaccumulated. She has since been
lost to follow-up.
272 CJASN
Figure 1. | Recommended algorithm for the management of a patient with kidney failure and pericarditis. HD, hemodialysis. aWith fluid
analysis for cell count and differential; gram and acid-fast stain; bacterial, mycobacterial, and fungal culture; adenosine deaminase; PCR for
tuberculosis; and cytology.
Disclosures
R.J. Rosen is an editorial intern for American Journal of Kidney
Diseases. The remaining author has nothing to disclose.
Funding
None.
Author Contributions
R.J. Rosen conceptualized the study; R.J. Rosen was responsible
for investigation; R.J. Rosen wrote the original draft; and A.M. Valeri
reviewed and edited the manuscript.
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