Bài giảng managing chronic heart failure patient in chronic kidney disease – BS trần hữu hiền

Managing Chronic Heart Failure Patient in Chronic Kidney Disease BS TRẦN HỮU HIỀN ĐHYK PHẠM NGỌC THẠCH 1... CARDIO-RENAL SYNDROMES CRS GENERAL DEFINITIONDisorders of the heart and kidney

Managing Chronic Heart Failure Patient

in Chronic Kidney Disease

BS TRẦN HỮU HIỀN ĐHYK PHẠM NGỌC THẠCH

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 Angiotensin-converting enzyme inhibitors

 Angiotensin II receptor blockers

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U.S Renal Data System USRDS 2012 Annual Data Report: Atlas of ChronicKidney Disease and

End-Stage Renal Disease in the United States Bethesda, MD: National Institutes of Health,

National Institute of Diabetes and Digestive and Kidney Diseases; 2012

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CARDIO-RENAL SYNDROMES (CRS) GENERAL DEFINITION

Disorders of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other

ACUTE CARDIO-RENAL SYNDROME (TYPE 1)

Acute worsening of cardiac function leading to renal dysfunction

CHRONIC CARDIO-RENAL SYNDROME (TYPE 2)

Chronic abnormalities in cardiac function leading to renal dysfunction

ACUTE RENO-CARDIAC SYNDROME (TYPE 3)

Acute worsening of renal function causing cardiac dysfunction

CHRONIC RENO-CARDIAC SYNDROME (TYPE 4)

Chronic abnormalities in renal function leading to cardiac disease

SECONDARY CARDIO-RENAL SYNDROMES (TYPE 5)

Systemic conditions causing simultaneous dysfunction of the heart and kidney

House AA, Anand I, Bellomo R, Cruz D, Bobek I, Anker SD, Acute Dialysis Quality Initiative Consensus Group Defiition and classifiation of

cardio-renal syndromes: workgroup statements from the 7th ADQI consensus conference Nephrol Dial Transplant 2010;25(5):1416–20

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Modification of risk factors *

1 Smoking cessation

2 Exercise

3 Weight reduction to optimal targets

4 Lipid modification recognizing

5 Optimal diabetes control HbA1C <7% (53 mmol/mol)

6 Optimal BP control <130/80 mm Hg

7 Aspirin is indicated for secondary prevention but not primary prevention

8 Correction of anemia to individualized targets

* KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease

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Major clinical role in reducing fluid overload

in patients with chronic HF and pulmonary

congestion*

*Eur Heart J 2005 Jun;26(11):1115-40 Epub 2005 May 18.

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 First-line loop diuretics GFR ≤30 mL/min per 1.73 m2

 The dosage of the loop diuretic should be progressively increased

until the effective dose is reached

 Intravenous bolus more effective than oral dose, because bypassing

the gastrointestinal tract overcomes impaired drug absorption due

to gut edema seen in advanced HF

 The effective oral or intravenous dose of loop diuretics should be

administered as often as needed to maintain the response

World J Cardiol 2010 May 26; 2(5): 112-117

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Diuretic Resistance

 Sequential blockade of sodium reabsorption in the nephron can be

instituted by administering a distal-acting diuretic, such as

hydrochlorothiazide or metolazone, along with a loop diuretic in a

dose determined according to the patient’s renal function

 Continuous intravenous infusion of diuretics may be more effective

in resistant cases, prevents the post-diuretic salt retention associated

with sequential doses*

* J Am Coll Cardiol 1996 Aug;28(2):376-82.

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Diuretic Adverse Effects

 Decrease in renal function

 Hypovolemia

 Hypokalemia

 Hyponatremia

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Angiotensin-converting enzyme

inhibitors

 Patients with chronic HF, mild-to-moderate renal insufficiency should

not be viewed as a contraindication to ACE inhibitor therapy, and a

mild and nonprogressive worsening of renal function during initiation

of therapy should not be considered an indication to discontinue

treatment, as the drug may offer the dual benefit of reducing

disease progression in both the heart and the kidney

Arch Intern Med 2000 Mar 13;160(5):685-93.

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Angiotensin-converting enzyme

inhibitors

 In patients with moderate or severe renal insufficiency, therapy with

low doses of ACE inhibitors should be initiated and the dose should

be increased gradually with careful monitoring of renal function and

serum electrolytes

World J Cardiol 2010 May 26; 2(5): 112-117

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Angiotensin-converting enzyme

inhibitors

 When the initiation of ACE inhibitor therapy leads to an increase in

serum creatinine levels >30% above baseline

 ACE inhibitors should be discontinued,

 The patients should be evaluated for conditions causing renal

hypoperfusion: excessive depletion of circulating volume due to

intensive diuretic treatment, concurrent administration of

vasoconstrictor agents [most commonly, nonsteroid anti-inflammatory

drugs (NSAIDs)] and severe bilateral renal artery stenosis Unless renal

vascular disease is present, therapy with an ACE inhibitor can be

reinstituted after correction of the underlying cause of reduced renal

perfusion

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World J Cardiol 2010 May 26; 2(5): 112-117

Risk of hyperkalemia associated

with ACE inhibitors*

 Discontinuation of drugs known to interfere with renal potassium

excretion (e.g NSAIDs, including cyclooxygenase-2 inhibitors),

 Administration of a low potassium diet

 Sodium bicarbonate in patients with metabolic acidosis

 A potassium level of >5.5 mEq/L should prompt a reduction in the

ACE inhibitor dose

*N Engl J Med 2004 Aug 5;351(6):585-92.

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Angiotensin II receptor blockers

 Alternative in patients intolerant of ACE inhibitors due to cough,

 Combination with ACE inhibitors in patients who remain severely

symptomatic on conventional therapy

Am Heart J 2007 Jun;153(6):1064-73.

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 Recommended for all patients with stable mild, moderate or severe

HF who are on standard treatment including diuretics and ACE

inhibitors*

 In the SOLVD study, treatment with beta-blockers was associated

with a 30% decrease in the risk of worsening renal function, both in

the ACE inhibitor and the placebo groups (RR 0.70, 95% CI

0.57-0.85)**

*J Am Coll Cardiol 2004;44:1587-1592 **Am Heart J 1999 Nov;138(5 Pt 1):849-55.

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 Not affect survival but led to a 28% reduction in HF hospitalizations

 Used safely in patients with HF and renal insufficiency,

 Initiated without a loading dose and maintained at a low dose

(0.125 mg), alternating days

 Serum digoxin levels should be monitored to maintain a serum

concentration in the acceptable range of 0.5-1.0 ng/mL

 Monitor carefully for symptoms and signs of digoxin toxicity

N Engl J Med 1997 Feb 20;336(8):525-33.

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Oxidative stress and hemodialysis patients

 Supplementation with 800 IU/day vitamin E reduces

composite cardiovascular disease endpoints and myocardial infarction*

 Treatment with acetylcysteine (600 mg

BID) reduces composite cardiovascular end points**

**Circulation 2003 Feb 25;107(7):992-5.

*Lancet 2000;356:1213-1218.

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HOME MESSAGE

 Modification of risk factors

 ACE inhibitors, ARBs, and β-blockers are the fist-line drugs treat HF in

CKD

 Loop diuretics are the first line treat fluid overload

 Digoxin use low dose (0.125mg) and close monitoring

 Oxidative stress and hemodialysis patients: vitamin E

and acetylcysteine

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THANKS FOR LISTENING

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