Managing refractory uraemic pericarditis with colchicine

Sir,

Pericarditis is a complication of end-stage renal disease (ESRD), still occurring in 20% of uraemic patients before and at the initiation of haemodialysis [1]. Multiple factors contribute to the appearance of uraemic pericarditis, which responds readily to treatment and has a good prognosis in the majority of cases. We present a patient with ‘refractory uraemic pericarditis’ who ultimately responded to colchicine. The use of colchicine in uraemic patients with pericarditis has not been reported previously.

A 48-year-old woman, suffering from ESRD due to autosomal dominant polycystic kidney disease, attended our clinic in August 2000. She manifested tachycardia and deep heart tones without fever, dyspnoea, thoracic pain or cough. Laboratory tests were compatible with ESRD. There was no leukocytosis. Chest X-ray, electrocardiogram and heart ultrasound revealed a large amount of pericardial effusion (anterior wall, 9 mm; posterior wall, 17 mm), diastolic dysfunction and hypertrophy of the left ventricle; the ejection fraction remained within a satisfactory range (65%). The patient was enrolled in daily 3 h haemodialysis sessions without anticoagulation. A week later, a new ultrasound exhibited persistent pericardial effusion (anterior wall, 7 mm; posterior wall, 15 mm). Moreover, after 3 weeks of intensive dialysis, a progression of the effusion was noticed (anterior wall, 12.4 mm; posterior wall, 21.1 mm), while the ejection fraction remained stable. The patient's condition was also stable, except for a mild tachycardia. Because of the progression, daily haemodialysis was continued for a further 2 weeks, during which a detailed search for accompanying diseases was completed, with negative results [white blood cells = 6000/mm3, anti-netutrophil; antibody (–), anti-DNA (–), C3 = 1.531 g/l, C4 = 0.42 g/l, erythrocyte sedimentation rate = 98 mm, C-reactive protein = 12.8 g/l, fibrinogen = 5.27 g/l, etc.]. While the adequacy of dialysis was reconfirmed, the pericardial effusion did not change. Methyl-prednisolone at a dose of 40 mg/day was added, and a month later we noticed a moderate reduction of the effusion (anterior wall, 8.4 mm; posterior wall, 13.1 mm). The administration of methylprednisolone was tapered over 2 months to full cessation. However, 1 month after its discontinuation (6 months after the initiation of dialysis), a new increase in pericardial effusion was observed (anterior wall, 15 mm; posterior wall, 16 mm). The patient received a new course of steroid (1 mg/kg body weight), but a month later pericardial effusion had progressed further. Since the patient remained haemodynamically stable, the surgeon's opinion was against intervention.

The type of surgical procedure utilized for cardiac tamponade is usually determined by local experience and by the condition of the patient. Acute cardiac tamponade with circulatory collapse should be treated with pericardiocentesis. On the other hand, pericardiocentesis is not recommended for effusions that do not produce circulatory compromise. The morbidity and the potential of mortality (due, for example, to right ventricular laceration) in this setting are not insignificant. In the literature, there are two justified indications for pericardiotomy or pericardiectomy: (i) any recurrence (and certainly more than one recurrence) if accompanied by cardiac tamponade; and (ii) if a recurrence is manifested principally by persistent pain, despite a trial of intensive medical treatment and evidence of serious steroid toxicity [2,3]. None of the above conditions were met in the present case. Our review of the literature led us to the administration of colchicine, 2 mg per day for 5 weeks, followed by 1 mg and then 0.5 mg per day, for a total of 18 months. Steroids were gradually tapered and finally stopped after 6 weeks.

Seven weeks after the initiation of colchicine, the pericardial effusion was diminished (anterior wall, 13.5 mm; posterior wall, 15 mm). Further reduction of the pericardial effusion was noticed 4 months after the initiation of colchicine (anterior wall, 7.6 mm; posterior wall, 9.7 mm); 6 months later, the remaining effusion did not exceed 5–6 mm. Thirty-six months later, the patient remains free of pericarditis.

In this rare case of resistant pericarditis, we used colchicine after the failure of intensive dialysis and steroids administered for an adequate time. In a review of the available data, Adler et al. reported numerous cases of non-uraemic recurrent pericarditis treated effectively with colchicine [4]. Colchicine is considered to exert its action through the inhibition of nucleated blood cell function and motility by blocking intracytoplasmic microtubule polymerization. This occurs independently of the underling inflammatory process [5]. Some authors recommend its use even as an initial treatment of acute pericarditis. Satisfactory results are obtained with sufficient doses for an adequate time [6]. The administration of small doses of colchicine, as an alternative treatment of refractory pericarditis, is included in guidelines of the World Heart Federation [7], but its use in uraemic patients has not been reported in the literature. In the present case of intractable pericardial effusion, colchicine proved to be helpful, efficient and safe.

Conflict of interest statement. None declared.

Sofia Spaia, Stavros Patsalas, Argiri Agelou, Charouli Theodoroglou, Nikolao Askepidis, Michalia Pazaroglou and Hizaklis Ioannidis

Renal Department 2nd Hospital of IKA Thessaloniki Greece E-mail: renalika{at}the.forthnet.gr

References

  1. Denker BM, Chertow GM, Owen WF Jr. In: Brenner and Rector, eds. The Kidney, 6th edn. WB Saunders; 1998: 2413–2414
  2. Shabetai R. Recurrent pericarditis Copyright© 2003 UpToDate® www.uptodate.com (800) 998-6374 (781) 237-4788
  3. Wood JE, Mahnensmith RL. Pericarditis associated with renal failure: evolution and management. Semin Dial 2001; 14: 61[CrossRef][ISI][Medline]
  4. Adler Y, Finkelstein Y, Guindo J et al. Colchicine treatment for recurrent pericarditis. A decade of experience. Circulation 1998; 97: 2183–2185[Abstract/Free Full Text]
  5. Wahl SM, Wahl LM, McCarthy JB. Lymphocytes mediated activation of fibroblast proliferation and collagen production. J Immunol 1978; 121: 942–946[Abstract]
  6. Millaire A, Durlaux G. Treatment of acute or recurrent pericarditis with colchicine. Circulation 1991; 83: 1458–1459
  7. World Heart Federation. Council on Cardiomyopathies: Task Force on Pericardial Disease. Protocol 1. November 1997




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