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Nephrology Mini-Symposium: Acute Cardiorenal Syndrome

Nephrology Mini-Symposium: Acute Cardiorenal Syndrome. R3 潘思宇 ,R3 李宗育 ,R3 張凱迪 ,R3 柯雅琳 R5 王介立 /VS 林水龍 Nov. 24 th , 2010. Fluid Management: Diuretic Therapy. Characteristics of Loop Diuretics Bolus versus infusion Diuretic resistance. IV Medication for Treating Heart Failure.

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Nephrology Mini-Symposium: Acute Cardiorenal Syndrome

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  1. Nephrology Mini-Symposium:Acute Cardiorenal Syndrome R3潘思宇,R3李宗育,R3張凱迪,R3柯雅琳 R5王介立/VS林水龍 Nov. 24th, 2010

  2. Fluid Management: Diuretic Therapy Characteristics of Loop Diuretics Bolus versus infusion Diuretic resistance

  3. IV Medication for Treating Heart Failure The ADHERE study (Acute Decompensated Heart Failure National Registry )All Enrolled Discharges (n=105,388) October 2001–January 2004 100 88% 90 80 70 60 Patients (%) 50 40 30 10% 10% 20 6% 6% 3% 1% 10 0 IV Diuretic Milrinone Nesiritide Nitroglycerin Nitroprusside Dopamine Dobutamine IV Vasoactive Meds Emerman CL, et al, J Card Fail, 2004; 10(4): s116-117

  4. Diuretics Use and Acute Kidney Injury • Lack of beneficial effects evidence on prevention or treatment of AKI • Minimize fluid overload Ronco C, et al, Contrib Nephrol. Basel, Karger, 2010, vol164, pp153-163

  5. Pharmacokinetics of Diuretics ND: not determined *: conflicting date D. Craig Brater, N Engl J Med 1998; 339:387-395

  6. Bolus or Infusion: which is better? • Drawbacks of Bolus loop diuretics • Prolonged periods of sub-therapeutic drug levels  rebound reabsorbtion • Higher concentration  higher toxicity Felker GMet al., Circ Heart Fail 2009;2:56-62.

  7. Bolus or Infusion: which is better? • Meta-analysis: Patients > 18 y/o with CHF Class III-IV • 24-hr total urine output Salvador DR et al., Cochrane Database Syst Rev 2005:CD003178.

  8. Bolus or Infusion: which is better? • Tinnitus and hearing loss • Hypokalemia and Hypomagnesemia Salvador DR et al., Cochrane Database Syst Rev 2005:CD003178.

  9. Bolus or Infusion: which is better? • Meta-analysis: Patients > 18 y/o with CHF Class III-IV • 24-hr total urine output Salvador DR et al., Cochrane Database Syst Rev 2005:CD003178.

  10. Causes of Diuretic Resistance in HF • Decreased renal function and distal Na+ delivery • Variability in diuretic absorption (bioavailability) • Neurohormonal activation (RAAS/SNS) • Drugs/diet—increased sodium intake • Noncompliance with medications • Infrequent dosing 1. Neuberg et al. Am Heart J. 2002;144:31-38. 2. Brater. N Engl J Med. 1998;339:387-395. 3. Wilcox. J Am Soc Nephrol. 2002;13:798-805.

  11. Management of Diuretic Resistance in Acute CRS • Restrict daily fluid intake (1.0–1.5 L) • Moderate restriction of daily salt intake (≤2 g) • Avoid NSAIDs • Give short-acting loop diuretic orally in several divided (and increasing) doses, bolus, or continuous intravenous administration • Use sequential nephron blockade via combination loop diuretic and thiazide diuretic • Consider short-term acetazolamide in selected patients Ellison DH et al., Diuretics. In: Brenner BM, Rector FC, eds. Brenner & Rector's the kidney. 8 ed; 2008.

  12. CASE PRESENTATION Beyond the Scarce Evidence… Still room for improvement Check BW!! (unless refused by p’t) Examine the diet at bedside Then, perhaps, cIF would be better

  13. Loop Prescription Empty bladder in 1 hour Slow infusion Until (+) diuretics response Max: Furosemide (or equivalent) 1gm/day Loading before infusion Ellison DH et al., Diuretics. In: Brenner BM, Rector FC, eds. Brenner & Rector's the kidney. 8 ed; 2008.

  14. Summary • We recommend simultaneously different methods for fluid assessment • For hospitalized patients, continuous infusion of loop diuretics may be better than bolus • Give loading dose before continuous infusion • Avoid rapid IV push

  15. Old Treatment (1974)…

  16. Never Fade Away (2007)…

  17. ULTRAFILTRATION (the same “F” word) CVVHF SLED-f SCUF GFR ISO-UF

  18. CASE PRESENTATION When GFR Fails…

  19. HD Room or ICU? HD Room • Isolated UF • HD ICU • IPD • SCUF • SLED(-f) • CVVH(D)F Do We Have a Third Place (Choice)?

  20. Peripheral Ultrafiltration

  21. Peripheral Ultrafiltration Aquadex 100TM

  22. The UNLOAD Trial Costanzo MR, et al. Journal of the American College of Cardiology 2007;49:675-83.

  23. The UNLOAD Trial • A prospective, randomized,multicenter trial • June 2004~ July 2005 • Patient: Hypervolemic patient hospitalized for heart failure • Excluding • Serum Cre > 3.0mg/dL • SBP < 90 mmHg • ACS

  24. Primary End Point: Weight Loss at 48 Hr

  25. Freedom From Re-hospitalization for Heart Failure

  26. Advantage of Isolated Ultrafiltration • Remove more sodium from body( “Isotonic” fluid removal) • Avoid activation of RAAS Costanzo MR, et al. Journal of Cardiac Failure 16(4): 277-284. Guazzi DM, et al. Br Herat J 1994; 82:534-539

  27. Diuretics Activate Neurohormonal Systems in HF 50 1000 Mean, 95% Confidence Interval 600 10 Plasma Renin Activity (ng/mL/h) Plasma Aldosterone (pmol/L) 2.5 200 0.5 P =.0007 100 P =.0002 After Diuretic (n=11) After Diuretic (n=11) Before (n=12) Before (n=12) Bayliss et al. Br Heart J. 1987;57:17

  28. Indication of Aquadex System 100TM

  29. Recommendations for Ultrafiltration If all diuretic strategies are unsuccessful, ultrafiltration or another renal replacement strategy may be reasonable.Consultation with a kidney specialist may be appropriate before opting for any mechanical strategy to affect diuresis. ACA/AHA Hunt SA, et al. Circulation 2009;119:e391-e479

  30. Recommendations for Ultrafiltration For patients with HF and renal dysfunction, venovenous ultrafiltration may be considered. In highly selected patients, intermittent slow continuous venovenous ultrafiltration may be considered. This should be performed in consultation with a nephrologist or a specialist physician who has experience using ultrafiltration in a setting of close inpatient observation. CCA ArnoldJM, et al. Can J Cardiol 2007;23:21-45.

  31. Recommendations for Ultrafiltration Consider ultrafiltration for management of renal failure in HF patients. Ultrafiltration should be considered to reduce fluid overload (pulmonary edema and/or peripheral edema) in selected patients and correct hyponatremia in symptomatic patients refractory to diuretics. ESC Dickstein K, et al. Eur J Heart Fail 2008;10:933-89.

  32. Key Difference?

  33. Not Without Cons • “Forget about peripheral access, beeps way to much…” • “We did it without a real problem with a 4:1 ratio on a Cardiac tele floor” • “We had our PICC line team inserting them and they worked well with a #18 gauge peripheral.”

  34. Ultrafiltration in HD Room Isolated UF • 5kg/4hr • Dialysate off • (+) heparin Sequential UF • 3kg/2hr with dialysate off • 1kg/2hr with dialysate on • (前兩小時純脫水，後一小時加透析)

  35. Effect of “No Dialysis” • More stable hemodynamic (less fluid shift into ICF) • Stable serum electrolyte, UN, CRE (no metabolic complications related to dialysis)

  36. UF: Rate Prescription? • ESRD • Maximal recommended rate 10 mL/kg/hr • Acute fluid overload • Dictated by rate of refill and cardiac reserve • No physiological upper limit • Limited by the membrane (TMP)and blood flow (Qb=200 mL/min, Max UF = 4L/hr) • Each hypotensive episode is detrimental to renal outcome Himmelfarb Jet al. N Engl J Med 2010;363:1833-45.

  37. Ancillary Care (Ward) • Check BW before & after the procedure • Detail review of the vital signs change during and after each UF episode • Determine the physiologic goal (BW, CXR, etc…) • DC the diuretics and monitor the spontaneous U/O • Keep recording U/O • Always watch out for urine retention • Laboratory monitor: as for ARF

  38. Key Points 100% Pre-dilution Low volume Anti-coagulation Focus on net I/O, rather than machine I/O RoutineKCl (unless contraindicated)

  39. Nurse Flowsheet(Q1H) 前HR不足 機器實脫 淨I/O目標 機器設定 病人 病人 病人 I O I/O Determined by volume state assessment

  40. UF Sliding Scale http://www.crrtonline.com

  41. Summary • Peripheral ultrafiltration device is an emerging tool for the treatment of cardiorenal syndrome, type 1. • Success of ultrafiltration for acute cardiorenal syndrome lies on meticulous manipulation of ultrafiltration

  42. TAKE HOME MESSAGE

  43. We’ve Only Just Begun • Many opinions (review articles), but few good quality clinical trials • Cardiorenal awareness – more researches to be done (both bench and bedside)

  44. Back to the Case… HD Room or ICU? - Cardiac reserve? - Respiratory reserve? - UF goal? - Urgency? - Resource?

  45. Furosemide Monotherapy Causes Significant Decline in Renal Function (GFR) Change in GFR after IV furosemide 80 mg in CHF 15 Placebo 10 5 0 -5 GFR (% Change) IV furosemide -10 -15 -20 -25 0 500 1000 1500 2000 2500 Urine Output (mL) 0–8 h Gottlieb et al. Circulation. 2002;105:1348.

  46. Ronco C, et al, J Am CollCardiol 2008; 52(19): 1527-39

  47. Retrospective, 2006/1~2007/3, CCU, Italy WRF:↑Cre > 0.3 mg/dL , ADHF, Total: 200, PSF: 102, RSF: 98 • Preserved systolic function: LVEF > 50% Not significant Cesar A. Belziti et al, Rev Esp Cardiol. 2010;63(3):294-302

  48. Central venous pressure • Mechanism • Venule hypertension and compression of tubule -> Tubular hypertension • CVP -> Renal v. -> interstitial HTN • Baseline CVP and GFR • Changing CVP and AKI Kevin Damman et al., J Am Coll Cardiol 2009; 53(7): 582–8

  49. Tubuloglomerular feedback Adenosine Brenner and Rector’s The Kidney, 8th ed http://www2.kumc.edu/ki/physiology/course/two/2_4.htm

  50. Problems on Prediction of AKI • Clinical predictive scoring system • Good NPV • Poor PPV • Newer biomarkers related to “kidney-injury” • Earlier diagnosis (not prediction) of AKI

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