DIEU TRI SUY TIM CKD

Managing Chronic Heart Failure Patient in Chronic Kidney Disease THS BS TRẦN HỮU HIỀN 1... Renal Data System.. USRDS 2012 Annual Data Report: Atlas of ChronicKidney Disease and End-Stag

Managing Chronic Heart Failure

Patient

in Chronic Kidney Disease

THS BS TRẦN HỮU HIỀN

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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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until the effective dose is reached

bypassing the gastrointestinal tract overcomes impaired drug

absorption due to gut edema seen in advanced HF

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

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

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Angiotensin-converting

enzyme inhibitors

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

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

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

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),

ACE inhibitor dose

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

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Angiotensin II receptor

blockers

symptomatic on conventional therapy

Am Heart J. 2007 Jun;153(6):1064-73.

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severe HF who are on standard treatment including diuretics and

ACE inhibitors*

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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hospitalizations

(0.125 mg), alternating days

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

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Oxidative stress and hemodialysis patients

composite cardiovascular disease endpoints and myocardial

HOME MESSAGE

HF in CKD

 acetylcysteine

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THANKS FOR LISTENING

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