Acute renal failure as the presenting symptom of pericardial effusion

Effects of pericardiocentesis on renal function and cardiac hemodynamics

BACKGROUND

Previous case studies have reported reversal of acute renal failure after pericardiocentesis in pericardial effusion. This study examines the effects of pericardiocentesis on preprocedural low cardiac output and acute renal dysfunction in patients with pericardial effusion.

METHODS

This is a retrospective study of 95 patients undergoing pericardiocentesis between 2015 and 2020. Pre- and post-procedure transthoracic echocardiograms (TTE) were reviewed for evidence of cardiac tamponade, resolution of pericardial effusion, and for estimation of right atrial (RA) pressure and cardiac output. Laboratory values were compared at presentation and post-procedure. Patients on active renal replacement therapy were excluded.

RESULTS

Ninety-five patients were included for analysis (mean age 62.2 ± 17.8 years, 58% male). There was a significant increase in glomerular filtration rate pre- and post-procedure. Fifty-six patients (58.9%) had an improvement in glomerular filtration rate after pericardiocentesis (termed "responders"), and these patients had a lower pre-procedure glomerular filtration rate than "non-responders." There was a significant improvement in estimated cardiac output and right atrial pressure for patients in both groups. Patients who had an improvement in renal function had significantly lower pre-procedural diastolic blood pressure and mean arterial pressure.

CONCLUSIONS

Pericardial drainage may improve effusion-mediated acute renal dysfunction by reducing right atrial pressure and thus systemic venous congestion, and by increasing forward stroke volume and perfusion pressure.

Acute renal failure during immediate post transplant period due to a pericardial effusion

Background

Pericardial effusions and acute renal failure are common findings in clinical practice. However, acute renal failure resulting from pericardial effusions (without tamponade) is a rare finding. We report the first such case to occur in a transplanted kidney.

Case presentation

A 20-year-old Sri Lankan male presented with hypertensive crisis in the background of end stage renal failure. He was thoroughly investigated for secondary causes of hypertension to no avail. He was hemodialysed adequately for 6 months, while being worked up for transplantation. He received an ABO matched, living donor transplant. Immediate post-operative period his urine outputs were poor, soon to became anuric by 6 h post-transplant. Elevated liver enzymes and non-specific increase of resistivity indexes (0.84–0.88) at the Doppler scan raised the possibility of venous hypertension. An echocardiogram showed a moderately large pericardial effusion which was tapped, and found to be a transudate. He started producing urine within 6 h, entered polyuric phase by day 3, and by day 7 his creatinine dropped to reference levels. Vasculitis screen, anti nuclear factor, viral screen, and rickettsia serology were negative. Albumin levels on day 2 were 27 g/l and were replaced using human albumin. The exact cause of pericardial effusion is unclear but hypoalbuminemia, drug-induced and idiopathic are possible causes. He has excellent graft function, no recurrences or constrictive pericarditis after 2 years follow.

Conclusion

We recommend any patient who has delayed graft function and raised central venous pressures to have an echocardiogram to exclude pericardial effusions. The response to pericardiocentesis had been universally good in reported cases.

Anuric acute renal failure associated with pericardial effusion without signs of cardiac tamponade

This article describes the anuric acute renal failure (ARF) secondary to massive pericardial effusion without tamponade in an 84 year-old man. He was referred to our emergency room with progressive dyspnea and azotemia. An electrocardiogram showed sinus tachycardia. A two-dimensional echocardiogram confirmed the presence of severe pericardial effusion without prominent ventricular diastolic collapse and there were no changes in his vital signs. Laboratory findings showed that his blood urea nitrogen and serum creatinine levels were 91.8 and 3.77 mg/dL, respectively. Renal ultrasonography showed no signs of hydronephrosis. Urine output did not increase in spite of giving a saline and furosemide infusion but increased immediately after pericardiocentesis with drainage. His renal function was completely restored 3 days after the procedure. A pericardial biopsy demonstrated invasion of malignant cells. We should keep in mind that pericardial effusion is one of the causes of anuric ARF, although it is not accompanied by tamponade.