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Management of renal impairment in the heart failure patient: The cardiologist perspective

Management of renal impairment in the heart failure patient: The cardiologist perspective. John Atherton Department of Cardiology, Royal Brisbane and Women’s Hospital Faculty of Medicine, University of Queensland Faculty of Health, Queensland University of Technology

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Management of renal impairment in the heart failure patient: The cardiologist perspective

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  1. Management of renal impairment in the heart failure patient: The cardiologist perspective John Atherton Department of Cardiology, Royal Brisbane and Women’s Hospital Faculty of Medicine, University of Queensland Faculty of Health, Queensland University of Technology Faculty of Science, Health, Education and Engineering, University of Sunshine Coast

  2. AstraZeneca: Hyperkalaemia advisory board Bayer Boehringer Ingelheim: Diabetes advisory board Bristol-Myers Squibb Eli Lilly: Diabetes advisory board Menarini Novartis: Heart failure advisory board Otsuka: Tolvaptan advisory board Servier Vifor Pharma: Hyperkalaemia medical advisory board DisclosuresHonoraria, sponsorship, or advisory boards (listed)

  3. Renal impairment in HF: Cardiologist perspective • Prevalence and relevance of renal impairment in HF • Worsening renal function in acute HF • HF therapies and renal impairment

  4. * Refers to last 12 months of ADHERE-Core module Adapted from Atherton JJ et al. J Cardiac Fail 2012;18:82-8.

  5. SWEDE-HF: HF mortality vs. eGFR 51% had eGFR <60 mL/min/1.73 m2 11% had eGFR <30 mL/min/1.73 m2 2% had eGFR <15 mL/min/1.73 m2 Löfman I et al. Open Heart 2016;3:e000324

  6. Bidirectional heart-kidney interactions Nephrol Dial Transplant (2010) 25: 1416–1420

  7. Renal impairment in HF: Cardiologist perspective • Prevalence and relevance of renal impairment in HF • Worsening renal function in acute HF • HF therapies and renal impairment

  8. Transient vs. persistent worsening renal function in AHF • ADHERE-US • 27,309 HF hosp. survivors >65 yrs • Transient WRF during hosp in 12% • Persistent WRF during hosp in 20% • Persistent WRF vs. no WRF: • - 1.73 (1.57-1.91) • Transient WRF vs. no WRF: • - 1.19 (1.05-1.35) • Persistent vs. transient WRF: • - 1.46 (1.28-1.66) 90d mortality Krishnamoorthy A et al. Am Heart J 2014;168:891-900.

  9. Interaction between worsening renal function and persistent congestion in AHF 762 HF hosp. survivors (Israel): WRF in 27% WRF: 51% persistent congestion Persistent congestion: Adjusted HR: 1.75 (1.40-2.19) Persistent WRF: Adjusted HR: 1.71 (1.31-2.35) Wattad M et al. Am J Cardiol 2015;115:932-7.

  10. Renal impairment and outcomes in heart failureSystematic review and meta-analysis Smith GL et al. J Am Coll Cardiol 2006;47:1987-96.

  11. Contributors to type 1 cardiorenal syndrome • Patient characteristics • Older age • Prior CKD/ proteinuria • Diabetes/ Obesity/ Hypertension*/ Anaemia/ Iron deficiency • Infection • Heart failure severity • Renal venous congestion • Arterial underfilling (reduced cardiac output/ perfusion) • High intra-abdominal pressure • Cachexia • Treatment related • Drugs (contrast, NSAID’s, antiobiotics, diuretics, RAAS blockers, chemotherapy) • Surgery • Large falls in systemic blood pressure (systolic, mean)* * correlated

  12. Thind GS et al. Cleveland Clin J Med 2018;85:231-9.

  13. J Physiol 1931;72:49-61

  14. Increasing venous pressure in isolated rat kidney at constant arterial pressure

  15. Increased CVP associated with impaired renal function 2,557 patients undergoing RHC >6 mmHg Damman K et al. J Am Coll Cardiol 2009;53:582-8.

  16. Clin Cardiol 2011;34:113-6.

  17. ESCAPE trial and registry (longitudinal analysis) No correlation (or weak paradoxical association) between CI and renal function • Multivariable analysis (n=575): • Natural log eGFR vs. • RAP: Beta = -0.01, P<0.001 • CI: Beta = -0.1, P=0.02

  18. Falls in BP associated with worsening renal function Voors AA et al. Eur J Heart Fail 2011;13:961-7 Dupont M et al. Eur J Heart Fail 2013;15:433-40 Testani JM et al. Eur J Heart Fail 2011;13:877-84

  19. ESCAPE trial: Worsening renal function without SBP-reduction or haemoconcentration associated with worse survival HR 2.7, P=0.005 HR 2.2, P=0.019 Testani JM et al. Eur J Heart Fail 2011;13:877-84

  20. Effects of venous congestion • Decreased renal perfusion pressure • Raised renal interstitial pressure increasing intratubular pressure thereby decreasing transglomerular pressure gradient • Raised intra-abdominal pressure compressing renal veins/ ureters • Sympathetic vasoconstriction/ RAAS activation • Renal parenchymal hypoxia • Proinflammatory cytokines • Decreased cardiac output through ventricular interaction

  21. Thind GS et al. Cleveland Clin J Med 2018;85:231-9.

  22. Reversible venous pooling with lower body negative pressure Radionuclide ventriculography Image adapted from Frank H et al. Kidney International 2003;63:617-23

  23. Effect of venous pooling in healthy controls and patients with heart failure Normal response Diastolic ventricular interaction “..,may explain why some patients with CHF paradoxically increase SV when PCWP is lowered with vasodilators.” Atherton JJ et al. Lancet 1997;349:1720-4

  24. Change in vascular resistance during venous pooling in CHF with or without diastolic ventricular interaction “Diastolic ventricular interaction in…CHF is associated with attenuated forearm vasoconstriction or paradoxical vasodilation during LBNP.” Atherton JJ et al. Circulation 1997;96:4273-9

  25. Renal impairment in HF: Cardiologist perspective • Prevalence and relevance of renal impairment in HF • Worsening renal function in acute HF • HF therapies and renal impairment

  26. ACEI + Beta blocker + MRA NYHA 2-3 NYHA 3-4 -31% -23% -34% -24% 12 month mortality -30% -38% 60-70% RRR mortality in HFrEF Hayman S, Atherton JJ. Cardiac Failure Review 2016;2:47-50.

  27. Renal impairment in HF: Cardiologist perspective • 40-60% of patients with HF have renal impairment, which is an independent risk marker for poorer outcomes. • 25-30% of patients with acute HF develop worsening renal function, which is associated with poorer outcomes if persistent and accompanied by persistent congestion. • Assessment of volume status is critical to allow appropriate management of worsening renal function in HF. • Renal venous congestion is a common (but not only) cause of worsening renal function in acute HF. • In HFrEF with stable CKD (stage 3,4), continuation/ up-titration of RAS blockers did not worsen long-term renal function; and down-titration of RAS blockers did not improve long-term renal function.

  28. CSANZ Annual Scientific Meeting – Hosted by CSANZ QLD 2-5 August 2018, Brisbane Convention and Exhibition Centre www.csanzasm.com

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