Pericardial_Involvement_in_ESRD - Pericardial Involvement...

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Unformatted text preview: Pericardial Involvement in Pericardial Involvement in ESRD Trina Banerjee Questions to be Answered 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 Outline of Presentation Outline of Presentation Differential of pericardial dz. in Dialysis Pts Uremic Pericarditis Dialysis Related Pericarditis Diagnosis Treatment Differential of Pericardial Differential of Pericardial Effusions in Dialysis Pts Uremic Pericarditis/Pericardial Effusion Dialysis Related Pericarditis/ Pericardial Effusion Volume Overload Pericarditis for Other Reasons Uremic Pericarditis Uremic Pericarditis Definition Definition Pericarditis either before or within 8 weeks of initiating renal replacement therapy Epidemiology Epidemiology 5% of people with advanced acute or chronic renal failure More common in younger patients More common in women Pathophysiology I 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 Pathophysiology II 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 Clinical Presentation Clinical Presentation Pleuritic Pain (32­82% of patients) Friction Rub (31­100% of patients) Dialysis Related Dialysis Related Pericarditis Definition Definition Pericarditis after 8 weeks of renal replacement therapy Epidemiology Epidemiology More common in younger patients More common in women Pathophysiology I Pathophysiology I Uncertain if pathophysiology is the same as in uremic pericarditis May be secondary to relatively inadequate dialysis Pathophysiology II Pathophysiology II Associated with the following: – Inadequate dialysis – Hypercatabolic conditions – Hyperparathyroidism – Infection (especially viral) Clinical Presentation Clinical Presentation Thoracic Pain (41­ 100%) Cough or dyspnea (31­57%) (93% with tamponade) Malaise (54­66%) Weight Loss (40%) Fever (75­100%) Chills (68%) Friction Rub (59­ 100%) Gallop Rhythm (66%) JVD (68­88%) Hepatomegaly (68%) Diagnosis Diagnosis Diagnosis Diagnosis EKG does not show typical ST segment and T wave changes Echo is used to assess the size of the effusion Treatment Treatment Uremic Pericarditis Uremic Pericarditis If hemodynamically unstable needs surgical intervention Dialysis with either HD or PD causes rapid improvement If fails to resolve in 7­10 days needs surgical intervention Important Facts about Important Facts about Dialysis Resolution rate 76­100% 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 Dialysis Related Dialysis Related Pericardial Effusion Treatment Depends on Size Treatment Depends on Size Large (>250cc pericardial effusion) – Drainage Medium and Small Effusions – Intensive Dialysis vs. Drainage Large Effusions Large Effusions Drainage Modality Depends Drainage Modality Depends on Hemodynamics Acute Tamponade or rapidly accumulating effusion – Pericardiocentesis Stable Large Effusion – Subxiphoid Pericardiotomy or Pericardiostomy – Pericardial Window – Pericardiectomy Pericardiocentesis Pericardiocentesis Involves putting a needle into the pericardium Recurrence rates as high as 70% Mortality rate 3­50% Complications include: Mycocardial laceration, Coronary artery laceration, and precipitation of tamponade Subxiphoid Pericardiotomy or 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 Subxiphoid Pericardiotomy or 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 2­3 days) Rutsky and Rostand Rutsky and Rostand Looked at 13 patients with dialysis related pericardial effusion treated with pericardiostomy and steroids 100% were effective 1 recurrence Pericardial Window 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 10­20mm Hg Drain is removed when the output of the tube is 50­100 mm Hg, usually in 3­4 days Left thoracotomy approach is used a variable sized window is created and chest tubes are inserted, usually for 4­5 days Pericardiectomy Pericardiectomy Performed under general anesthesia Thoracotomy Approach Figuera Study I 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 300­500 cc of fluid Figuera II 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 Small and Medium Small and Medium Effusions Intensive Hemodialysis Intensive Hemodialysis Definition: – Intensive dialysis is considered 4 hours a day for 10­14 days (Semin Dial. 1990; 3:21–25) Problems: – Anticoagulation should not be used – Hemodynamic shifts may be harmful – Electrolyte abnormalities Predictors of Poor Response Predictors of Poor Response to Intensive Hemodialysis T>102 Systolic BP <100 WBC>15 JVD, large pericardial effusion, and/or anterior and posterior pericardial effusions on the TTE Echo Frequency with Echo Frequency with Intensive Dialysis Standard practice is to repeat echo every 3­5 days during intensive dialysis to assess for change in volume Medical Management Medical Management NSAIDs 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 NSAIDs NSAIDs Rutsky and Rostand – Patients with dialysis pericarditis – 40 Treated with NSAIDs – 121 not – No clinical difference Steroids 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 1­3 weeks Steroids Steroids Eliason: – No clinical improvement and increase in infection and wound dehiscence after steroids ...
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