Cardiac Tamponade Secondary to Severe Uremic Pericarditis in the Modern Dialysis Era: A Case Report

Uremic pericarditis is currently an uncommon complication of end-stage renal disease (ESRD) in developed countries due to improved access to renal replacement therapy and earlier initiation of hemodialysis. Nevertheless, delayed or interrupted dialysis may still result in life-threatening manifestations, including massive pericardial effusion and cardiac tamponade. We present the case of a 44-year-old man with ESRD requiring hemodialysis, insulin-dependent type 2 diabetes mellitus, morbid obesity, hypertension, and heart failure with preserved ejection fraction who was admitted because of progressive dyspnea, generalized weakness, and systemic deterioration. Following the recent initiation of hemodialysis, renal replacement therapy was interrupted because of recurrent dialysis catheter dysfunction and discontinuation of dialysis care at an outside center. On admission, the patient presented in moderate-to-severe clinical condition with profound fluid overload estimated at approximately 30 liters above dry weight, respiratory distress, an inflammatory response, severe azotemia, and metabolic acidosis. Physical examination was diagnostically challenging because diffuse pulmonary crackles, wheezes, and coarse breath sounds obscured potential pericardial friction rub, while morbid obesity limited assessment of jugular venous distention.  Chest radiography demonstrated marked cardiomegaly with a globular "water bottle" configuration suggestive of massive pericardial effusion. Subsequent transthoracic echocardiography revealed a large circumferential pericardial effusion with echocardiographic signs of impending cardiac tamponade. Management included restoration and intensification of renal replacement therapy with repeated hemodialysis sessions and isolated ultrafiltration (IUF), broad-spectrum antimicrobial therapy, and multidisciplinary intensive care treatment. Pericardial fluid cultures remained sterile despite concomitant bloodstream infection associated with a severely contaminated dialysis catheter. Gradual clinical improvement was achieved with the reduction of hypervolemia and stabilization of hemodynamic status. This case highlights a rare but severe presentation of advanced uremic pericarditis occurring after interruption of renal replacement therapy. Despite being considered a largely historical complication in developed healthcare systems, severe uremic pericarditis should remain in the differential diagnosis in patients with ESRD presenting with progressive dyspnea, cardiomegaly, massive fluid overload, and hemodynamic instability.