S5770 Under Pressure: A Rare Presentation of Shock Liver Due to Pericardial Tamponade

Introduction: Ischemic hepatitis is the leading etiology of marked transaminase elevation in both the general population and patients with cirrhosis, accounting for nearly 50% of such cases. Pericardial tamponade is a rare cause of shock leading to ischemic hepatitis, accounting for less than 2% of cases. We report a rare case of ischemic hepatitis secondary to pericardial tamponade in a patient with end stage renal disease (ESRD) on peritoneal dialysis (PD). Case Description/Methods: A 53-year-old man with no known prior liver disease and multiple co-morbidities including ESRD on PD originally presented for a lower extremity wound infection. A few weeks into his hospitalization, he developed an acute rise in transaminases including aspartate aminotransferase of 1918 and alanine aminotransferase of 585, both of which were normal the day before. Other labs were notable for an international normalized ratio of 1.58, alkaline phosphatase of 170, total bilirubin of 0.5, and blood urea nitrogen and Cr of 51 and 7.4, respectively. Hemodynamics had been stable. Acetaminophen level was normal. A liver doppler ultrasound showed patent portal and hepatic veins. Viral hepatitis and autoimmune serologies were negative. Twelve hours after transaminase elevation, a stat computed tomography of the chest, abdomen, and pelvis was ordered to evaluate a new decline in mean arterial blood pressure. Imaging identified a new large pericardial effusion. This was confirmed on echocardiogram, which further showed tamponade physiology. The patient underwent emergent pericardiocentesis with pericardial drain placement, which was ultimately removed after 4 days. Transaminases normalized over the coming days. Discussion: Pericardial effusion and tamponade are known complications of patients receiving dialysis, often due to inadequate dialysis or build up of uremic toxins. Furthermore, patients receiving PD may be at even greater risk due to the unique structural risks associated with PD, such as peritoneo-pericardial fistula formation, that carries a specific risk of dialysate leakage into the pericardium. Although a rare cause of ischemic hepatitis in the general population, pericardial tamponade should be more heavily considered in patients receiving dialysis, particularly peritoneal dialysis.