Course and outcome of dialysis pericarditis in diabetic patients treated with maintenance hemodialysis

Pericardial effusion caused by viral pericarditis in a patient receiving peritoneal dialysis

Background

Acute pericarditis causes acute inflammation of the pericardium. Although most cases of pericarditis are idiopathic with no identifiable cause, its etiology can be infectious, such as viral, bacterial, mycotic, and tuberculous infections, or non-infectious, including post-pericardiotomy, metastatic malignant tumor, connective tissue disease, or uremia. However, there has been no report of pericarditis caused by adenoviral infection in patients undergoing peritoneal dialysis (PD). Herein, we report a case of pericarditis and pericardial effusion caused by adenoviral infection in a patient undergoing PD.

Case presentation

A 59-year-old man who had been undergoing PD in our department for 3 years had a bout of acute enteritis. He was later admitted to the emergency department of our hospital because of malaise and loss of consciousness due to pericardial effusion. Testing after admission revealed elevated adenovirus antibody titers. Pericardial effusion improved although no changes in his PD prescription were made. The patient was hospitalized and admitted to maintain hemodynamics and prevent hypotension. Since insufficient dialysis volume was ruled out by peritoneal equilibrium tests and dialysis volume assessment, the patient was kept under observation, and no changes were made regarding the method of dialysis. Pericardial effusion and the C-reactive protein level both gradually declined, and the patient’s weight remained steady. The adenovirus antibody titer alone increased to 1:64 at approximately 2 weeks after hospitalization. The final diagnosis was acute pericarditis due to adenoviral infection rather than uremia or dialysis-associated pericarditis.

Conclusions

We treated a patient with a rare case of pericardial effusion caused by viral (adenoviral) pericarditis in a patient undergoing PD. In addition to testing for the usual causes, uremic and dialysis-associated pericarditis must always be ruled out in patients receiving dialysis. In cases of pericarditis with a viral origin, diagnosis and treatment must be comprehensive.

Uremic pericarditis, pericardial effusion, and constrictive pericarditis in end-stage renal disease: Insights and pathophysiology

A rising prevalence of end-stage renal disease (ESRD) has led to a rise in ESRD-related pericardial syndromes, calling for a better understanding of its pathophysiology, diagnoses, and management. Uremic pericarditis, the most common manifestation of uremic pericardial disease, is a contemporary problem that calls for intensive hemodialysis, anti-inflammatories, and often, drainage of large inflammatory pericardial effusions. Likewise, asymptomatic pericardial effusions can become large and impact the hemodynamics of patients on chronic hemodialysis. Constrictive pericarditis is also well documented in this population, ultimately resulting in pericardiectomy for definitive treatment. The management of pericardial diseases in ESRD patients involves internists, cardiologists, and nephrologists. Current guidelines lack clarity with respect to the management of pericardial processes in the ESRD population. Our review aims to describe the etiology, classification, clinical manifestations, diagnostic imaging tools, and treatment options of pericardial diseases in this population.

Uremic pericarditis: a report of 30 cases and review of the literature

PATIENT

Male, 71 • Male, 69 • . Female, 49.

FINAL DIAGNOSIS

Uremic pericarditis.

SYMPTOMS

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MEDICATION

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CLINICAL PROCEDURE

Hemodialysis.

SPECIALTY

Nephrology.

OBJECTIVE

Rare disease.

BACKGROUND

Uremic pericarditis, common at one time among dialysis patients, has become a rare entity in recent years. Due to its low incidence, its recognition has gained importance among internists, cardiologists, and nephrologists. It can be seen in predialysis patients and in dialysis patients who are on hemodialysis or peritoneal dialysis.

CASE REPORT

We report 3 cases of uremic pericarditis and their presenting manifestations and review 30 cases we have treated. Among these patients, the traditional findings among patients with acute pericarditis such as chest pain, fever, electrocardiographic changes, and leukocytosis are uncommon. Pericardial friction rub has a relatively high incidence but its differentiation by an untrained ear, especially by a non-cardiologist, could be a major problem. Not infrequently, it is complicated by pre-tamponade or tamponade, requiring pericardiocentesis or pericardial surgery.

CONCLUSIONS

Uremic pericarditis is a treatable, but not always a preventable, condition. Timely recognition of its presence and its efficient management are essential elements of successful treatment.

Definite and probable septic pericarditis in hemodialysis

INTRODUCTION

Although the incidence of septic pericarditis in hemodialysis populations is less frequent in the modern antibiotic era, it is still a cause of death partly because diagnosis is sometimes difficult and uncertain.

METHODS

From 2002 to 2006, 12 out of a total of 12,213 maintenance hemodialysis patients were referred for management of septic pericarditis. Patients were diagnosed as either definite or probable septic pericarditis. A definite diagnosis of septic pericarditis is based on the discovery of pathogenic bacteria in pericardial effusion, whereas a probable diagnosis is based on the proof of bacterial infection elsewhere in a patient with otherwise unexplained pericarditis, or appropriate response to a trial of systemic antibiotics.

RESULTS

Four (33.3%) patients were diagnosed as definite pericarditis, whereas eight (66.7%) patients as probable pericarditis. It was found that although oxacillin-resistant Staphylococcus aureus (ORSA) (4/12 or 33.3%) and tuberculous (4/12 or 33.3%) pericarditis were common, salmonella pericarditis (2/12 or 16.7%) was also not uncommon. Pericardiocentesis, or pericardial window with pericardiectomy, was performed in three (25%) and two (16%) of patients with cardiac tamponade, respectively. Two patients died because of severe ORSA (1/12 or 8%) and salmonella (1/12 or 8%) sepsis. Finally, there were four (33%) patients who developed constrictive pericarditis after follow-up.

CONCLUSIONS

These data are important because the spectrum of septic pericarditis was clearly different between Taiwan and other developed countries. Furthermore, it is the only report in which patients were diagnosed as either definite or probable septic pericarditis, therefore improving the sensitivity of diagnosis as in the case of tuberculous pericarditis.

Association between body mass and mortality in maintenance hemodialysis patients

A total of 959 Taiwanese patients undergoing maintenance hemodialysis-102 underweight (BMI < 18.5 kg/m(2)), 492 normal weight (BMI 18.5-22.9 kg/m(2)), 187 overweight (BMI 23.0-24.9 kg/m(2)), and 178 obese (BMI >or= 25 kg/m(2)) were recruited into this three-year, multicenter longitudinal study. It was found initially that the underweight group had more females, longer hemodialysis durations, less use of a biocompatible membrane (BCM) dialyzer, higher erythropoietin doses and Kt/V(urea), and lower white blood cell counts, hemoglobin, serum creatinine and phosphate, and high sensitivity C-reactive protein (hsCRP) than other groups (P < 0.001). Furthermore, a chi(2)-test demonstrated that underweight patients had poorer nutrition (P = 0.023), but less systemic inflammation (P < 0.001) than other groups. A stepwise multiple linear regression analysis established that age, sex, diabetes mellitus, hemodialysis duration, use of BCM dialyzer, Kt/V(urea), creatinine, high-density lipoprotein cholesterol, and hsCRP were significant risk factors associated with BMI (P < 0.001-0.002). After three years, 149 (15.5%) patients had died, including 22 of 102 (21.6%) underweight patients, 64 of 492 (13.0%) normal weight patients, 38 of 187 (20.3%) overweight patients, and 25 of 178 (15.5%) obese patients. The primary causes of mortality were cardiovascular (52.3%) and infection (39.6%). A multivariate Cox regression analysis revealed that age, diabetes mellitus, BMI, albumin, hsCRP, and cardiothoracic ratio were significant risk factors associated with all-cause mortality over three years (P < 0.001-0.022). Finally, Kaplan-Meier analysis confirmed that underweight patients suffer higher mortality than other groups (Log rank, P = 0.0392); therefore, the data have demonstrated a survival disadvantage of low BMI in Taiwanese patients undergoing maintenance hemodialysis.