Transient early diastolic murmur and end stage renal disease

Abstract

Transient early diastolic murmur and end stage renal disease Sir, A transient early diastolic murmur may be heard in patients with end stage renal disease. This was initially attributed to aortic regurgitation secondary to fluid overload.' This view was supported by Alexander and Polak,2 who described the appearance of the murmur in seven patients with end stage renal failure during episodes of fluid overload; their description of the murmur supports their conclusions that it was of aortic origin. We have, however, had a patient in end stage renal failure in whom an early diastolic murmur was associated with episodes of typical pericardial pain while he was salt and water depleted. The murmur was loudest when he lay supine and it was clearly audible all over the praecordium. We believe that this observation supports the hypothesis of Barrett et al.3 that an early diastolic "murmur" may be a pericardial noise indicative of uraemic pericarditis. This possibility was not mentioned by Alexander and Polak. Barrett described eight patients and commented that the murmur was not typical of aortic regurgitation in that it was maximal in intensity at and localised to the cardiac apex and became softer when the patient leaned forward. Aortography in six of the patients identified only one patient with possible aortic regurgitation, while echocardiography showed that in all five patients examined a posterior pericardial effusion was present. They concluded that "the early diastolic murmur of renal failure does not usually arise from functional aortic incompetence but may be a sound of pericardial origin". Barrett's conclusions are not