Review Question - QID 104146

The presence of fever in this clinical scenario would significantly bolster the diagnosis of uremic pericarditis. This is because fever is often a concomitant feature of systemic inflammation induced by uremia.

Uremic pericarditis is generally observed in patients with advanced renal dysfunction, typically end-stage renal disease (ESRD). It manifests with a constellation of symptoms including pleuritic chest pain, dyspnea, and frequently fever. The pain is exacerbated when the patient is supine and ameliorated when leaning forward. The physical examination often reveals a pericardial friction rub best heard when the patient is leaning forward. Elevated levels of BUN (>60 mg/dL) are often present. Immediate hemodialysis is the cornerstone of treatment, leading to a swift resolution of symptoms and effusion.

Uremic pericarditis classically presents with dyspnea, cough, fever, and pleuritic chest pain, worse when the patient is supine and during inspiration and alleviated when the patient leans forward. Physical exam is remarkable for pericardial friction rub best heard with the patient leaning forward. An elevated JVP and pulsus paradoxus may also be present. Pericarditis occurs in 6-10% of renal failure patients (BUN > 60mg/dL). The most important therapy is hemodialysis (HD). Resolution is usually rapid and reduces size of pericardial effusion. Other treatment modalities commonly used for pericarditis from other causes (antinflammatory meds - NSAIDS, colchicine) are 2nd line agents after HD.

Rahman et al. discuss the complications of acute kidney injury, which is characterized by abrupt deterioration in kidney function. The spectrum of injury is wide, ranging from mild to advanced requiring renal replacement therapy. Renal replacement therapy (dialysis) has the following indications with acute kidney injury: refractory hyperkalemia; volume overload; intractable acidosis; uremic encephalopathy, pericarditis, or pleuritis; and removal of certain toxins.

Kleynberg et al. discuss pericardial involvement in ESRD, most commonly, acute uremic or dialysis pericarditis. Chronic constrictive pericarditis (CCP) is seen much less commonly. First line treatment for CCP is a partial pericardiectomy, but may require a total pericardiectomy.

Illustration A displays a gross pathological specimen of fibrinous pericarditis.

Incorrect Answers
Answer 1: Diffuse ST elevations are more indicative of other etiologies of pericarditis but are usually absent in uremic pericarditis.
Answer 2: Janeway lesions suggest infective endocarditis rather than pericarditis. Should the patient present with new valvular regurgitations or positive blood cultures, this could be a consideration.
Answer 4: A holosystolic murmur at the left sternal border could imply valvular heart disease, specifically mitral or tricuspid regurgitation, but is not characteristic of pericarditis.
Answer 5: An S4 heart sound is typically associated with conditions like hypertensive heart disease and is not a classical finding in pericarditis. In a different context, it might suggest diastolic dysfunction or ischemic heart disease.

Bullet Summary
The presence of fever, along with elevated BUN, pleuritic chest pain, and a pericardial friction rub, strongly suggests uremic pericarditis in a patient with ESRD. Immediate hemodialysis is the mainstay of treatment.