A 58-year-old man with advanced CKD (eGFR 12 mL/min) presents with pleuritic central chest pain that worsens on lying flat. Examination shows a pericardial friction rub. Echocardiography shows a small pericardial effusion without tamponade. What is the most appropriate next step in management?

• A Start high-dose NSAIDs and reassess in 2 weeks
• B Give IV heparin for suspected coronary thrombosis
• C Initiate urgent haemodialysis ✓
• D Perform immediate pericardiocentesis

Explanation

Uraemic pericarditis is an absolute indication for initiating dialysis (along with refractory hyperkalaemia, severe metabolic acidosis, fluid overload, and uraemic encephalopathy). It reflects inadequate clearance and typically resolves with dialysis. NSAIDs are avoided because they risk bleeding and further renal injury. Pericardiocentesis is reserved for tamponade, which is absent here. Heparin is contraindicated because haemorrhagic uraemic pericarditis may progress to tamponade.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.