Cardio Renal Syndrome In heart failure worse renal function worse outcome Renal function mortality risk with heart failure Multiple processes Systemic haemodynamics hypertension or hypotension ID: 1045443
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1. Andrew Durward 2017OrlandoCardio Renal Syndrome
2. In heart failure, worse renal function = worse outcomeRenal function = mortality risk with heart failureMultiple processesSystemic haemodynamics (hypertension or hypotension)Neurohormonal activation (Renin angiotensin)Intrarenal microvascular Cellular dysregulationOxidative stressKrumholtz Am J Cardiol. 2000;85:1110–1113.
3. Systemic effectLocal effectHumoral InflammatoryEpinephrineAngiotensinADHEndothelinAlteredsensitivityBNPNOUrodilatinGENETIC RISKApoptosisNecrosisHibernationtroponinAKI doesn’t mean ATNSystemic effect with distal organ damage possible12% PICU severe AKI11% mortality AKIvs 2.5% without23% shockNEJM 2017 KaddourahPathogenesis
4. Diuresis resistance – kidneys don’t work European Journal of Clinical Investigation (1994) 24, 632-639 URODILATINLocal renal natriuretic peptideInfusion improvesUrine outputLOCAL EFFECTARF post liver transplant
5. Cardio-renalor Reno-cardiacAcute or chronicDefinition (which comes first?)
6. Type 1) Acute cardio-renal (worsening cardiac function leads to AKI)Type 2) Chronic cardio-renalType 3) Acute reno-cardiac (fluid overload, arrhythmia K+, uremia)Type 4) Chronic reno-cardiacType 5) Secondary systemic disease Sepsis, hepato – renal syndrome and immune mediated diseaseDefinition and classification (which comes first?)Nephrol Dial Transplant (2010) 25: 1416–1420Acute hypertensive pulmonary oedema, cardiomyopathyAcute glomerular disease / nephritisChronic glomerular disease
7. 13% blood volumeGlobal versus regional haemodynamics13%Blood volume
8. SYSTEMIC VS REGIONAL PERFUSION J Clin Invest. 2011;121(11):4210-4221GLOBAL Sys BP CVP Acid base Lactate Mix Venous NIRS BiomarkersREGIONALDriving pressure= mean pressure - CVPRenal medulla ischaemia
9. Renal medullary ischaemia (Kidneys at limit of hypoxia)Regener Curr Opin Nephrol Hypertens. 2012 ; 21(1): 33–38Renal ischaemic perfusion injuryOxidative stress and inflammationMolecular adaptive responsesHaem OxygenaseANPAngiopoetinREPERFUSION INJURY
10. Polyuricoliguric 0 8 16 24 0 8 16 24polyuricExpected post bypass response is avid water retention (ADH)Polyuria can be pathologic (loss of renal concentrating capacity)
11. Cardiac bypass and AKI
12. Worsening renal function with acute decompensated heart failure25 to 33% with acute decompensated heart failure Associated with poor outcomesTiming and onset important (preventative strategies)75% AKI in 1st 4 days PICUBasu NEJM 2017;376Type 1 Cardio-renal syndrome (heart drives renal injury)
13. Treatment- avoid hypotension (thresholds?)Poukkanen et al. Critical Care 2013, 17:R29573Inotropes may AKI
14. Mullens J Am Coll Cardiol. 2009 Role of high CVP in AKI64% blood venous
15. Optimise diureticsVasodilatorsFluid unloadingCytoprotectionDiuresisHypovolaemiaFluid overloadHigh CVPVasodilationRenal impairment
16. Optimise diureticsVasodilatorsFluid unloadingCytoprotectionDiuretics +CVVHHypertonic salineGTN (venodilator)NitroprussideNesiritide (BNP)Higher vs lowerDose loop diureticsLoop diuretic infusionsCombination therapyAdenosine blockerDiuresisHypovolaemiaFluid overloadHigh CVPVasodilationRenal impairment
17. Gottlieb Circulation. 2002;105:1348-1353Plasma adenosine raised heart failure – local vasoconstrictorLocally produced in kidney (stress signal)Furosemide alonereduces GFROptimising diuretics : Adenosine blocker
18. Meta-analysis of Nesiritide = worsened cardiac failure (Sackner-Bernstein. Circulation 2005;111:1487-91)Low doses of nesiritide potentially renal protectiveN=7141O’Connor N Engl J Med 2011;365:32-43Vasodilators and Nesiritide (recombinant BNP)Controversial
19. Ultrafiltration (500ml/hr) versus Intravenous (IV) Diuretics for Patients Hospitalized for Acute Decompensated Congestive Heart Failure The ultrafiltration group = greater weight loss and volume removal at 48 h Dyspnoea score in both groups improved. Rehospitalisation and the total days of hospitalization were significantly lower in the ultrafiltration group at 3 monthsNo change renal function long termFluid unloading : UNLOAD trial (adults)
20. N=188 adult patients acute decompensated heart failureChange serum Cr and body weight at 96hrsFluid unloading : UltrafiltrationBart N Engl J Med 2012; 367:2296-230Ultrafiltration group Higher adverse events72% vs 57% at 60 days
21. Selective V2 antagonists (tolvaptan) to mobilize aquaresisEfficacy of Vasopressin Antagonist in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial 4133 patients (359 centers in 20 countries)Produced weight loss (sodium increase) No long-term benefit vs placebo groups1 year mortality 25.0% in the tolvaptan group and 26.0% in the placeboVasodilator: Vasopressin blocker (adults)
22. 7.2% Saline 6% HES vs 0.9% saline (4ml/kg)52 children post cardiac bypass (VSD)Favourable haemodynamic effectWithout added risk of tissue oedemaHypertonic saline: cardiac bypass (children)
23. N=43 children ECMO32% needed dialysis for ARF (double creatinine)Survival only 19% vs 92% if no renal injuryWeber Ann Thorac Surg. Nov; 1990 50(5):720–3Padden Pediatr Crit Care Med. 2011; 12(2): 153–158N=154 children CVVH On ECMO (44%)44% survived26% Ongoing CCRT96% recovered renal function at dischargePaediatric ECMO and AKI
24. Outcome Cardiorenal Syndrome (Children)Olowu, 2011, International Journal of NephrologyN=47 (Nigeria)34% Mortality20% Malaria
25. Am J Respir Crit Care Med Vol 187, Iss. 5, pp 509–517, 2013Cell death rare in sepsis-induce cardiac dysfunctionfocal cardiac mitochondrial injuryRenal tubular injury common but present focally; renal tubular regeneration can occurOrgan injury is potentially reversible (hibernation) TUBULAR CELL ADAPTATION
26. Cardiorenal syndrome UNIFIED THEORYSYSTEMIC PROCESSInflammationHypertension/HypotensionCardiac hormonal axis activatedLOCAL PROCESSMicrocirculatory dysfunctionBioenergetic failureTUBULAR CELLADAPTATIONTorgersen Anesth Analg 2009;108:1841–780% sepsis deaths unresolved infectious focus (autopsy)50% undetected pneumonia
27. Conclusion – Cardio Renal syndromeHeart failure with worsening renal function Varying chronicity and presentationPathogenesis complex (haemodynamic and local renal factors)Poor outcome if untreatedTherapeutic potential ( treat cause and supportive treatment)