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Cardiorenal Syndrome Dr Matt Hall Consultant Renal Physician

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Cardiorenal Syndrome Dr Matt Hall Consultant Renal Physician Cardiorenal syndrome Dr Matt Hall Consultant Renal Physician Tuesday, 26 November 2019 • A 72 year old with ischaemic cardiomyopathy is admitted with breathlessness and oedema. • DH: Ramipril 5mg od, Bisoprolol 5mg od, Furosemide 80mg od, Spironolactone 25mg od. • Blood pressure is 115/68 and weight has increased from 95 to 103kg in 3 weeks. • Furosemide was increased to 80mg bd. Bloods checked in a week. • Results: Na 130 K 6.0, Creat 310 (from baseline 135µmol/l), urea 32.5 26/11/2019 Overview • Cardiorenal syndromes • The role of the kidney in heart failure • Medical management: friend or foe? • Strategies • The role of renal replacement therapies in heart failure 26/11/2019 1. What are “cardio-renal syndromes”? 26/11/2019 Cardiorenal syndromes “A syndrome in which acute or chronic dysfunction of the renal or cardiac system induces acute or chronic dysfunction in the other” 26/11/2019 26/11/2019 Cardiorenal syndromes Type Initial event Secondary dysfunction Type 1 Acute heart dysfunction Acute kidney injury (eg, cardiogenic shock) Type 2 Chronic heart dysfunction Progressive renal ischaemia and fibrosis (eg, valvular heart disease) Type 3 Acute kidney failure Fluid overload, dysrhythmia (eg, Goodpasture syndrome) Type 4 CKD Cardiac hypertrophy, fibrosis and (eg, diabetic nephropathy) dysrhythmia Type 5 Multi-organ failure (eg, septic shock) 26/11/2019 2. The kidney is involved in the body’s response to heart failure 26/11/2019 High output Low output failure failure Arterial Increased venous underfilling pressure Carotid Juxtaglomerular Atrial and baroceptors apparatus ventricular stretch Sympathetic Renin activation secretion ↑ANP ↑ BNP ↑Vasopressin ↑Ang II ↑Aldosterone H O Na+ and H O 2 Vasoconstriction 2 retention retention 26/11/2019 High Low output output failure failure Arterial Increased venous underfilling pressure Carotid Juxtaglomerular Atrial and baroceptors apparatus ventricular stretch Sympathetic Renin activation secretion ↑ANP ↑ BNP ↑Vasopressin ↑Ang II ↑Aldosterone H O Na+ and H O 2 Vasoconstriction 2 retention retention 26/11/2019 2. Heart failure treatments inhibit kidney adaptation to heart failure 26/11/2019 Maintaining GFR 26/11/2019 Renal auto-regulation Tubuloglomerular Neurohumoral Myogenic feedback fedback ↓MAP ↓ GFR ↓ MAP ↓ Afferent arteriolar ↓ Adenosine release stretch ↑Ang II ↑Adr ↓ Afferent arteriolar ↓ Afferent arteriolar vasoconstriction vasoconstriction ↑ Afferent and efferent arteriolar Afferent Efferent vasoconstriction arteriole arteriole Efferent > afferent arteriolar vasoconstriction 26/11/2019 Renal auto-regulation Tubuloglomerular Neurohumoral Myogenic feedback fedback ↓MAP ↓ GFR ↓ MAP ↓ Afferent arteriolar ↓ Adenosine release stretch ↑Ang II ↑Adr ↓ Afferent arteriolar ↓ Afferent arteriolar vasoconstriction vasoconstriction ↑ Afferent and efferent arteriolar Afferent Efferent vasoconstriction arteriole arteriole Efferent > afferent arteriolar vasoconstriction 26/11/2019 Maintaining GFR 26/11/2019 Decreased Increased Heart failure glomerular creatinine etc filtration etc Decreased Na Decreased renal and water flow to tubules blood flow Diuretic resistance Decreased diuretic delivery to loop of Henle Heart failure treatments 26/11/2019 Improve Impair renal survival function Improve Impair renal symptoms autoregulation Improve heart Risk acute function decompensation 26/11/2019 4. Strategies 26/11/2019 Set expectations: patients will fall off their perch 26/11/2019 26/11/2019 Adapt, Monitor, Adapt, Monitor, Adapt, Monitor… 26/11/2019 Adapt and monitor • Titrate diuretics daily to achieve a suitable rate of fluid loss – 0.5-1.0kg/day (500-1000ml/day) as a guide • Reduce diuretics when euvolaemic or diuresing too fast • Empower patients to titrate their own diuretics on discharge 26/11/2019 Don’t optimise ACEi or ARB until fluid status is reasonable… 26/11/2019 26/11/2019 Don’t optimise ACEi or ARB until fluid status is reasonable… …but restart as soon as possible and don’t be scared if eGFR drops No matter how much eGFR drops after starting an ACEi, it’s better to be on one than not… …unless you make the potassium is 8.0mmol/l Diuretics aren’t nephrotoxic* - renal under-perfusion is *except sometimes… 26/11/2019 You need more molecules of furosemide in the circulation to get some of them to the nephron Increased doses are needed in CKD 26/11/2019 There isn’t an eGFR where heart failure drugs are safe or not But the risks of AKI and electrolyte disturbances with ACEi, ARBs, spiro, diuretics increases with decreasing eGFR I wouldn’t commence an ACEi at eGFR<20 ml/min but wouldn’t stop it if they are stable and already established 26/11/2019 Sick day rules for patients taking ACEi/ARB …then re-start! 26/11/2019 • A 72 year old with ischaemic cardiomyopathy is admitted with breathlessness and oedema. • DH: Ramipril 5mg od, Bisoprolol 5mg od, Furosemide 80mg od, Spironolactone 25mg od. • Blood pressure is 115/68 and weight has increased from 95 to 103kg in 3 weeks. • Results: Na 130 K 6.0, Creat 310 (from baseline 135µmol/l), urea 32.5 26/11/2019 1. Admit 2. Withhold spironolactone and ramipril 3. Either try furosemide 120mg bd orally or 80mg bd IV 4. Ensure fluid and salt restriction 5. Increase IV diuretic until achieving >1.5-2.0l/day urine output 6. Convert to oral furosemide or bumetanide once oedema resolving 7. Reintroduce ACE inhibitor when approaching euvolaemia 8. Reintroduce spironolactone when AKI and hyperkalaemia resolved 9. Prepare patient and clinicians that we might have to do it all again. 26/11/2019 5. The magic wand 26/11/2019 26/11/2019 Fluid overload Cured Electrolyte disturbance Acidaemia 26/11/2019 Ultrafiltration Haemodialysis/ haemofiltration Peritoneal dialysis 26/11/2019 26/11/2019 Isolated ultrafiltration – not effective in acute setting 26/11/2019 Published March 1st 2018 • Death • Heart failure hospitalisation • ED attendance 26/11/2019 Haemofiltration 26/11/2019 Haemofiltration p<0.001 26/11/2019 Haemodialysis • 5 case series and observational studies in last 10 years • No RCT Bad experiences Theoretical harm 26/11/2019 Haemodialysis p<0.001 26/11/2019 Hemodialysis-induced repetitive myocardial injury results in global and segmental reduction in systolic cardiac function. Burton JO1, Jefferies HJ, Selby NM, McIntyre CW. Clin J Am Soc Nephrol. 2009 Dec;4(12):1925-31. 26/11/2019 Peritoneal dialysis • 21 case series and observational studies in last 5 years • No RCT 26/11/2019 Need to treat 3-5 pts with CAPD for 1 year to prevent 1 death or admission with decompensated heart failure 26/11/2019 26/11/2019 26/11/2019 Spironolactone ACEi/ARB Entresto Palliation Β-blocker Loop diuretics ± thiazide Loop diuretics Ivabradine HFrEF CRT? ICD? HFpEF RRT Loop diuretics Loop diuretics ± thiazide CABG/PCI Valve surgery Heart transplant 26/11/2019 Summary Renal function deteriorates because of heart failure and heart failure treatments Managing cardio-renal syndromes has been, is, and will always be difficult 26/11/2019 .
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