A 2019 expert analysis discusses randomized clinical trials which evaluated the use of colchicine in acute pericarditis and recurrent pericarditis. Of the available studies, none evaluated the safety or efficacy of colchicine specifically in a population of patients with renal impairment or end-stage renal disease. Additionally, the clinical trials did not analyze renal-specific baseline characteristics; therefore, it is unknown whether patients with end-stage renal disease were included. [1], [2], [3], [4], [5], [6]
A brief letter to the editor reports a case of ‘refractory uraemic pericarditis’ who ultimately responded to colchicine. A 48-year-old female with end-stage renal disease (ESRD) due to autosomal dominant polycystic kidney disease manifested tachycardia and deep heart tones without fever, dyspnoea, thoracic pain, or cough. The imaging revealed a large amount of pericardial effusion (anterior wall, 9 mm; posterior wall, 17 mm), diastolic dysfunction, and hypertrophy of the left ventricle, and the ejection fraction remained within a satisfactory range (65%). Despite intensive hemodialysis sessions (e.g., daily 3-hour hemodialysis sessions), pericardial effusion persisted and progressed, while remaining stable on ejection fraction. In addition to continued daily hemodialysis, methylprednisolone at a dose of 40 mg/day was added which resulted in a moderate reduction of the effusion a month later. Nonetheless, while the patient remained hemodynamically stable, pericardial effusion has progressed further despite another new course of steroids (1 mg/kg). Finally, 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 was given. 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) and further reduced at 4 months (anterior wall, 7.6 mm; posterior wall, 9.7 mm). Approximately 6 months later, the remaining effusion did not exceed 5 to 6 mm, and the patient remained free of pericarditis 36 months later. This is a rare case of resistant pericarditis in which colchicine was utilized after the failure of intensive dialysis and steroids administered for an adequate time. [7]
A 2017 review states colchicine should generally be avoided in patients with advanced renal impairment. Colchicine is not cleared by dialysis and needs to be renally dose-adjusted during dialysis. It should only be used for short-term treatment. In the European Society of Cardiology guidelines on pericarditis, colchicine is contraindicated in end-stage renal disease (ESRD) patients; however, clinically used in small doses for a duration of up to 3 months. [8]
There is a general reluctance to use colchicine in renal impairment, even in conditions with relatively established indications. Some authors recommend complete avoidance of colchicine in patients with a creatine clearance less than 10 mL/min and patients undergoing hemodialysis but this is not based on firm evidence. Based on one study, the authors of a 2017 review state colchicine can be used safely in patients receiving hemodialysis when started on low doses and under close clinical surveillance. [9]