Dialysis-related constrictive pericarditis: old enemies may sometimes come back

ABSTRACT Cardiovascular disease is the main cause of death in patients with chronic kidney disease (CKD). Several heart conditions have been associated with CKD, including myocardial and pericardial diseases. This paper describes a case of Dialysis-related constrictive pericarditis in a patient diagnosed with sudden hypotension during a hemodialysis session. A 65-year-old man diagnosed with hypertension, diabetes, obesity, and cirrhosis on hemodialysis for two years complained of symptoms during one of his sessions described as malaise, lipothymia, and confusion. The patient had a record of poor compliance with the prescribed diet and missed dialysis sessions. He was sluggish during the physical examination, and presented hypophonetic heart sounds, a blood pressure of 50/30mmHg, and a prolonged capillary refill time. The patient was referred to the intensive care unit and was started on antibiotics and vasoactive drugs. His workup did not show signs of infection, while electrocardiography showed low QRS-wave voltage. His echocardiogram showed signs consistent with a thickened pericardium without pericardial effusion. Cardiac catheterization showed equalization of diastolic pressures in all heart chambers indicative of constrictive pericarditis. The patient underwent a pericardiectomy. Examination of surgical specimens indicated he had marked fibrosis and areas of dystrophic calcification without evidence of infection, consistent with Dialysis-related constrictive pericarditis. Hypotension for unknown causes must be considered in the differential diagnosis of dialysis patients.

【摘要】心血管疾病是慢性肾脏病（Chronic Kidney Disease，CKD）患者的首要死亡原因。多种心脏病症与CKD相关，包括心肌疾病与心包疾病。本文报道1例透析相关缩窄性心包炎（Dialysis-related constrictive pericarditis）患者，该患者在血液透析（Hemodialysis）期间突发低血压。该患者为65岁男性，既往有高血压、糖尿病、肥胖症及肝硬化病史，接受血液透析治疗已2年，某次透析过程中出现全身乏力、晕厥前驱症状及意识模糊等不适。患者存在饮食依从性不佳、漏透析的既往史。体格检查显示患者反应迟钝，心音低钝，血压为50/30mmHg，毛细血管充盈时间延长。患者被转入重症监护病房（Intensive Care Unit，ICU），并予以抗生素及血管活性药物治疗。相关检查未发现感染征象，心电图（Electrocardiography）提示QRS波群电压降低。超声心动图（Echocardiogram）可见心包增厚，但无心包积液。心导管检查（Cardiac Catheterization）显示各心腔舒张压趋于相等，符合缩窄性心包炎的表现。患者随后接受了心包切除术（Pericardiectomy）。手术标本病理检查提示存在显著纤维化及营养不良性钙化区域，无感染征象，与透析相关缩窄性心包炎的诊断相符。临床工作中需注意，对于透析患者出现的不明原因低血压，需将该病纳入鉴别诊断范畴。