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The Cardiorenal Syndrome A Cardiologist’s Perspective

The Cardiorenal Syndrome A Cardiologist’s Perspective. J Thomas Heywood Director, Heart Failure Program Scripps Clinic, La Jolla, California. Disclosures. Consulting: Medtronic Research: St Jude, Medtronic, Speakers Bureau: Otsuka, Actelion, Medtronic.

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The Cardiorenal Syndrome A Cardiologist’s Perspective

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  1. The Cardiorenal SyndromeA Cardiologist’s Perspective J Thomas Heywood Director, Heart Failure Program Scripps Clinic, La Jolla, California

  2. Disclosures Consulting: Medtronic Research: St Jude, Medtronic, Speakers Bureau: Otsuka, Actelion, Medtronic

  3. High Prevalence of Renal Dysfunction and Its Impact on Outcome in 118,465 Patients Hospitalized With Acute Decompensated Heart Failure: A Report From the ADHERE Database J. Thomas Heywood MD et al J Card Failure Sept 2007 65% Have at least Moderate renal dysfunction

  4.   8.35% (n=67640) 2.31% (n=20820) 2.88% (n=24469) SBP 115 (n=2,702) 5.67% (n=3882) Inpatient mortality from ADHERE Registry Based on admission BUN, creatinine and BP < BUN 43 (n=32220) < <  SBP 115 (n=6697) 15.30% (n-1863) 5.63% (n-4834) < Cr 2.75 (n-1862) 19.76% (n-592) 13.23% (n-1270) Analysis of patients in the National Acute Decompensated Heart Failure National Registry (ADHERE) BUN=blood urea nitrogen, Cr=serum creatinine, SBP-systolic blood pressure Fonarow GC et al. J Cardiac Fail 2003;9(suppl 1):S79.

  5. Why is renal function abnormal in patients with heart failure?

  6. Worsening renal function (> 25% increase in creatinine or BUN during treatment for acute decompensation) Difficulty in diuresis without worsening renal function ACE intolerance due to hypotension or hyperkalemia in severe heart failure Chronic renal insufficiency complicating HF therapy The cardiorenal syndrome (CRS)Definition Heart failure with…

  7. Role of the kidney in congestive heart failure: Relationship of CI to kidney function Ljungman, Cody Drugs 1990;39 Suppl 4:10-21

  8. RBF, p<.05 with Group A RVR, p<.01 with Group A Renal Blood Flow Renovascular Resistance Role of the kidney in congestive heart failure: Relationship of CI to kidney function Ljungman, Cody Drugs 1990;39 Suppl 4:10-21

  9. Role of the kidney in congestive heart failure: Relationship of CI to kidney function CI, p<.001 with Group A BUN, p<.01 with Group A GFR/BUN Creatinine was not different between the groups. BUN better indicated low CI and GFR than creatinine Ljungman, Cody Drugs 1990;39 Suppl 4:10-21

  10. ` Am J Cardiol 2006:97:1759

  11. High CVP significantly impairs GFR 0 6.25 12 18.75 25 0 Central Venous Pressure Effect of increasing central venous pressure on GFR in dogs, constant BP 1.4 GFR ml/min P< .05 Raised Venous Pressure: A direct cause of renal sodium retention Firth et al Lancet 5/7/88 1.1 P< .05 0.8 0.5 mm Hg

  12. Effect of Increased Renal Venous Pressure on Renal Function Doty J et al J of Trauma: Injury, Infection and Critical Care 1999 47:1000-1005 • Swine where anesthetized, instrumented and a unilateral nephrectomy preformed. • In the remaining kidney the renal vein was constricted in half the animals to obtain a renal venous pressure of 30, the other animals served as controls P <.05 between groups

  13. Renal Decapsulation in the Prevention of Post-Ischemic Oliguria Stone HJ Annals of Surgery 1977:343-355 • 15 rhesus monkeys, 1 hour suprarenal aortic clamping to produce ATN, after which the renal capsule was stripped from one kidney. The ureters of each kidneys were catheterized to collect urine for creatinine, urea and free water. P <.01

  14. Prevalence of Worsening Renal Function During Hospitalization According to Categories of Admission CVP, CI, SBP, and PCWP Mullens, W. et al. J Am Coll Cardiol 2009;53:589-596

  15. What is the fluid status? Is the blood pressure adequate for renal perfusion? What is the cardiac output? Is there evidence of high central venous pressure? Is there intrinsic renal disease? Treatment of the Cardiorenal Syndrome 5 important questions…

  16. Overdiuresed or intercurrent illness results in volume loss and renal dysfunction Give fluids, stop diuretics and IV vasodilators Often a reluctance to give fluids to HF patients but it may be critical in this situation and time is of the essence to avoid irreversible renal damage HypovolemicCardiorenal Syndrome Too Dry!!!

  17. Poor renal perfusion due to high central venous pressure Usually CVP > 15-20 mm Hg coupled with reduced blood pressure Diuretics often held because of worsening renal function and misguided idea of “ intravascular volume depletion” Continue diuretics to reduce central venous pressure Ultrafiltration CRS due to high central venous pressure Too Wet!!!

  18. Low CO and hence renal hypoperfusion due to HF mediated vasoconstriction (Ang II, endothelin induced increased afterload) CO is low and SVR high, often over 1800-2000 ACEI and vasodilators very useful since CO can increase significantly if afterload normalized. Actual improvement in renal function may be seen May need temporary inotropic support if systolic BP <80 as vasodilators are added CRS with vasoconstriction Clamped Down!!!

  19. May improve CO in some patient and hence increase effective renal perfusion ACEI may lower BP to the point where effective renal perfusion is impaired With chronic renal disease, there is hyperfiltration in the remaining nephrons. ACEI decreases efferent arteriole constriction and hence decreases glomerular capillary pressure which may preserve renal function longterm This may result in a 10-20% increase in creatinine, but over the long term renal function is preserved ACEI play a complex role in renal function in HF

  20. Circulation 2001:104:1985-1991

  21. ACEI intolerance in low CO, low SVR states GFR Declines GFR Maintained Circulation 2001:104:1985

  22. CRS due to inadequate renal perfusion because of low CO and/or BP, Nml SVR!!! Inotropes, Pressors, Temporary circulatory support LVAD CRS with normal SVR but low CO or BP “ No Pump!!!”

  23. “Although there is no serum creatinine level per se that contraindicates ACE inhibitor therapy, greater increases in serum creatinine occur more frequently when ACE inhibitors are used in patients with underlying chronic renal insufficiency.”

  24. Heart Mate 2

  25. Severe Renal Dysfunction Complicating Cardiogenic Shock is not a contraindication to Mechanical Support as a Bridge to Transplant Khot UN et al JACC 2003

  26. Renal hypoperfusion due to low perfusion; CO may be normal but SVR and BPlow Vasodilators worsen BP and hence renal perfusion Stop of ACEI, especially if SVR is low Rule out sepsis Pressors, Inotropes, ? Vasopressin Consider transplant or ventricular assist device if renal dysfunction is felt to be reversible CRS with vasodilation “Vasodilated!!”

  27. 10/23 VAD patients with low blood pressure and increased cardiac index Despite pressors, SVR still decreased 5 received saline placebo for 15 minutes and 5 vasopressin (.1 Units/min, 3 patients in placebo group were blindly crossed over No change in BP in placebo group MAP increased from 61 to 87 in the Vaso group with increase in SVR from 729 to 1374, with significant reduction in NE dose NE was able to be weaned off in 4/5 patients within 15 minutes A Prospective Randomized Trial of Arginine Vasopressin in the Treatment of Vasodilatory Shock after Assist Device Placement Argenziano et al Circ 1997 Suppl II 290

  28. Consider intrinsic renal disease (IRD) or diuretic resistance syndrome, renal artery stenosis Probable IRD when long hx of HTN and/or diabetes, look for proteinuria, renal artery stenosis Trial of loop diuretic infusion, combination with distal tubular diuretic Add nesiritide Consider ultrafiltration CRS with normal CO and SVR “It’s the Kidneys, Not the Heart!!!!””

  29. Renal Adaptation to Diuretics Ellison DH. Am J Kidney Dis. 1994;5:623. Stanton and Kaissling Am J Physiol 1988 255:F1269

  30. Invasive hemodynamic monitoring should be considered in a patient: • who is refractory to initial therapy, • whose volume status and cardiac filling pressures are unclear, • who has clinically significant hypotension (typically SBP !80 mm Hg) or worsening renal function during therapy, Or • who is being considered for cardiac transplant and needs assessment of degree and reversibility of pulmonary hypertension, Or in whom documentation of an adequate hemodynamic response to the inotropic agent is necessary when chronic outpatient infusion is being considered. (Strength of Evidence 5 C) HFSA Guildelines 2010

  31. Cardiac Output = VTI x Area of Outflow Tract x Heart Rate 8cm/sec x 3cm x 80 beats/min = 1920 ml/min, 1.9 L/min

  32. Hemodynamic Echo-The Noninvasive swan • Right Atrial pressure (Inferior Vena Cava) • Pulmonary Artery Pressure (TR Velo + RA) • Estimated mean left atrial pressure (E/Eʹ) • Cardiac Output (VTI x Area x HR) • Systemic Vascular Resistance (MAP-RA)x80/CO 130/70 = Mean 130+140/3= 90 (90-20) x 80/1.9= 5600/1.9 = SVR approx 2800 i.e. vasoconstricted

  33. Case Study • 56 yo male with ICM, CABG 1998, ICD 2001 EF 10% • Dec 2011 admitted with AF another hospital • Dec 19 Admitted Scripps for dyspnea, angioplasty of OM2, Diagonal and PDA grafts, RA 15, PA 64/34, Wedge 20, Fick 2.5 L/min, PA Sat 54% • Discharge Furo 20, Carvedilol 3.125 bid, Lis 2.5 • wt 77.4 Kg

  34. Mr CB Did well for one week, admitted another hospital for pneumonia • Seen post discharge and digoxin was started for Afib, EF 7% referred back to Scripps • On Admission, Dyspneic, weight 75 KG • Gen- A/Ox3 but very fatigued • Neck- JVD to jawline, (+)AJR • Heart- Irreg, tachy, 105bpm, 2/6 systolic murmur • Lungs- CTAB • Ext- no edema, cool to touch

  35. Mr CB 1/12 creatinine 1.8 • 1/13 Echo EF 14%, PA sys 48, RA 10, Ascited, LVOT 6 cm • 1/13-14 attempted to diuresis, poor UO, Creat 2.2 • 1/16 Cardioverted, CRT placed • 1/17 Creat 2.9, 350 cc urine/24hr HF consult • BP 80-90 systolic, cold extremities-Cardiogenic Shock

  36. Initial Swan results in ICU • RA = 22 • RV = 43/22 • PAP = 41/26(30) • PCWP = 22 • CO/CI = 1.87/1.0 by Fick • PA sat 33%,

  37. What to do?

  38. Intervention • Dobutamine IV 5 mcg/kg/min • Titrate to SBP>90 • Dopamine IV 3 mcg/kg/min • Nitroprusside IV 0.5 mcg/kg/min • maintain SVR 1200-1500 • Hold for SBP<90 • Lasix and Zaroxolyn for diuresis

  39. PA CVP CO/CI SVR

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