Pericarditis with or without effusion as a complication of end-stage renal disease responds to the institution of chronic dialytic therapy. The management of pericardial effusion which has its onset after some time of chronic dialytic therapy is less well established. Since a surgical pericardial drainage procedure is often performed on an emergency basis in some patients with pericardial effusion treated with maintenance dialysis, it would be advantageous to be able to predict which patients would subsequently require an operation which then could be performed electively. Thus, we reviewed our experience with pericardial effusion in patients treated with maintenance dialysis in order to ascertain whether one or more factors would predict the ultimate need for a surgical pericardial drainage procedure. Our analysis of 22 patients with pericardial effusion demonstrates that those with a large effusion are best treated by elective pericardial drainage using a subxiphoid approach with instillation of triamcinolone hexacetonide into the pericardial sac. Those patients with a small or moderate effusion can be subjected to a trial of nonsteroid anti-inflammatory drugs and/or intensive dialysis. Evidence of an enlarging effusion should prompt surgical drainage before hypotension or tamponade require the patient to undergo an emergency operation.