Pericardial Effusion in Renal Disease: To Tap or Not to Tap

Abstract

The natural history of pericardial effusions attributable to renal disease is variable. Although aggressive hemodialysis may lead to the resolution of some effusions, some reports suggest that prompt drainage is optimal. We describe a case of a 49-year-old woman who presented with end-stage renal disease and a large pericardial effusion. Although she was hypertensive on presentation and had no pulsus paradoxus, transthoracic echocardiography revealed stigmata of cardiac tamponade, including right atrial and ventricular collapse, as well as a plethoric inferior vena cava. Because of the lack of certain clinical signs of tamponade and due to concern about excess bleeding risk in the setting of uremia, the effusion was initially managed with serial dialysis rather than pericardiocentesis. The effusion did not decrease in size despite 1 week of hemodialysis, and the patient developed acute dyspnea, relative tachycardia and hypotension after an increase in the blood flow rate during hemodialysis, all of which resolved with a decrease in the blood flow rate. The onset of dyspnea during a session of dialysis as a symptom of tamponade physiology has not been reported previously. We believe that this case supports early pericardiocentesis in patients with any degree of echocardiographic evidence of tamponade. We discuss this in the context of existing literature, which suggests that pericardiocentesis, rather than dialysis, is the preferred management strategy for large uremic pericardial effusions, even in the absence of evidence of clinical signs of pericardial tamponade.

Pericarditis and Pericardial Effusions in End‐Stage Renal Disease

“…Small (hemodynamically insignificant) effusions are commonly seen on echocardiograms in the setting of acute pericarditis. The incidence of pericardial effusion has been reported to be ~70–100% in mixed populations of uremic and dialysis‐associated pericarditis ().…”

“…Data on outcomes are derived mainly from surgical case series assessing efficacy of different procedures. Some advocate drainage of all effusions related to pericarditis , while others recommend urgent drainage of large effusions since initiation of dialysis (for uremic pericarditis) or intensification of dialysis (for dialysis‐associated pericarditis) with rapid reduction in preload would unmask or worsen tamponade physiology . Others recommend continued TTE surveillance to gauge response to conservative therapies first, with surgical intervention if signs of enlarging effusion or ventricular collapse become apparent .…”

“…Diagnosis can be supported by presence of a pulsus paradoxus (fall in systolic blood pressure of 10 mmHg or more with inspiration during normal respiration) or electrical alternans on EKG. However, it is important for clinicians to know that pericardial tamponade can have subtle presentations without hypotension, tachycardia, or pulsus paradoxus . This can result from a relatively small amount of fluid that rapidly accumulates (such as with intrapericardial hemorrhage) or from a large amount of fluid accumulating slowly over time (the pericardium may accommodate two or more liters before occurrence of tamponade) .…”