Nephrology Mini-Symposium: Acute Cardiorenal Syndrome R3 潘思宇,R3 李宗育,R3 張凱迪,R3...
-
Upload
kelley-mills -
Category
Documents
-
view
308 -
download
0
Transcript of Nephrology Mini-Symposium: Acute Cardiorenal Syndrome R3 潘思宇,R3 李宗育,R3 張凱迪,R3...
![Page 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. 24 th, 2010.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/1.jpg)
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
![Page 2: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/2.jpg)
“Cardiorenal” for 100 Years• Sir Thomas Lewis (1881-1945)
Lewis T., Br Med J 1913;2:1417-20
![Page 3: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/3.jpg)
PubMed Trend
NIH Definition
Ronco Classification
![Page 4: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/4.jpg)
Working Definition (2004)
At its extreme, cardio-renal dysregulation leads to what is
termed “cardio-renal syndrome” in which therapy to relieve congestive symptoms of heart failure is limited by further decline in renal function. It is clear that our current understanding of cardio-renal connections is inadequate to explain many of the clinical observations in heart failure or to direct its therapy.
NHLBI Working Group. http://www.nhlbi.nih.gov/meetings/workshops/cardiorenal-hf-hd.htm
![Page 5: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/5.jpg)
Proposed Classification (2008)
Acute Chronic
HeartKidney
KidneyHeart
Ronco C. et al. J Am Coll Cardiol 2008;52:1527-39.
(cardiorenal)
(renocardiac)
![Page 6: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/6.jpg)
Cardiorenal Syndrome is Always There
Type 2 and 4
Type 3
![Page 7: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/7.jpg)
This year, 2010, we present you the…
Type 1 Cardiorenal Syndrome
Acute decompensated heart failure
Acute myocardial infarction
Low cardiac output syndrome post cardiac surgery
![Page 8: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/8.jpg)
There’s Always a Problem…CASE
PRESENTATION
![Page 9: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/9.jpg)
Acute Cardiorenal Syndrome
Epidemiology & Pathophysiology. R3 潘思宇Diagnosis & Management......…... R3 李宗育Volume & Diuretics………………. R3 張凱迪Ultrafiltration………………………. R3 柯雅琳
R5 王介立VS 林水龍
![Page 10: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/10.jpg)
Cardiorenal Syndrome Type I
• Acute heart disorder leading to acute kidney injury
• Acute heart disorder ?– Acute decompensated heart failure– Acute coronary syndrome– (Low cardiac output syndrome after open heart surgery)
• Acute kidney injury ?– ARF, Worsening renal function– AKI: RIFLE, AKIN, K-DIGO– Biomarkers: NGAL, cystatin C
![Page 11: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/11.jpg)
Epidemiology
Acute decompensated heart failure
Acute coronary syndrome
![Page 12: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/12.jpg)
Acute decompensated heart failure
![Page 13: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/13.jpg)
Observational, 2002/10~2004/10, FranceWRF:↑Cre > 0.3 mg/dL, Total: 416 with AHF
WRF: 37%WRF: 37%
D. Logeart et al, Int J Cardiol 2008; 127: 228–232
![Page 14: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/14.jpg)
Event: death or unscheduled readmission for HF
P = 0.01P = 0.01
D. Logeart et al, Int J Cardiol 2008; 127: 228–232
![Page 15: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/15.jpg)
Acute coronary syndrome
![Page 16: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/16.jpg)
Observational, 1994/1~1996/2, Total: 147007 with AMIMild: ↑0.3~0.4, Mod: ↑0.5~0.9, Severe: ↑ 1.0 mg/dL≧
CR Parikh et al, Arch Intern Med. 2008;168(9):987-995
7.1%7.1% 7.1%7.1%
5.2%5.2%
![Page 17: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/17.jpg)
Observational, 1994/1~1996/2, Total: 147007 with AMIMild: ↑0.3~0.4, Mod: ↑0.5~0.9, Severe: ↑ 1.0 mg/dL≧
P < 0.01P < 0.01At all time pointsAt all time points
CR Parikh et al, Arch Intern Med. 2008;168(9):987-9951 yr 10 yr5 yr3 yr
![Page 18: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/18.jpg)
Pathophysiology
The low flow state hypothesis
Venous congestion: IAP & CVP
Others: Neurohormonal activation
![Page 19: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/19.jpg)
JG Abuelo et al, N Engl J Med 2007; 357(8): 797-805
Pgc
PT
Pgc: Glomerular pressure, PT : Tubular pressure
πgc: Glomerular colloid p, πT : Tubular colloid p
△π
GFR GFR αα ( ( Pgc - PT - △π)
![Page 20: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/20.jpg)
• Pgc
– MAP?– Intra-Abdominal hypertension?– Change of Resistance at A or E arteriole?
• PT
– Intra-Abdominal hypertension?– Tubular obstruction?
Factors affect GFRPPgcgc αα (MAP – IAP) (MAP – IAP)MAPMAP αα Pgc α α GRFGRF
![Page 21: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/21.jpg)
Franklin H. Epstein et al, N Engl J Med 1999; 341(8): 577-585
![Page 22: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/22.jpg)
If this low output theory holds true, then …
↓LVEF / CI ↓GFR
這病人 Kidney 不好
灌水 Dopamine !!!
↓Renal Renal perfusionperfusion??
![Page 23: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/23.jpg)
Prospective, 1990, USA, CHF, Total: 34A: CI>2 ; B: CI 1.5~2 ; C: CI <1.5 L/min/m2
Ljungman et al. Drugs 1990; 39(Suppl. 4): 10-21
Autoregulation
![Page 24: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/24.jpg)
Renal auto-regulation
Brenner and Rector’s The Kidney, 8th edhttp://www2.kumc.edu/ki/physiology/course/two/2_4.htm
![Page 25: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/25.jpg)
• Pgc
– MAP?– Intra-Abdominal hypertension?– Change of Resistance at A or E arteriole?
• PT
– Intra-Abdominal hypertension?– Tubular obstruction?
Factors affect GFR
PPTT αα IAPIAP
PPgcgc αα (MAP – (MAP – IAPIAP))
![Page 26: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/26.jpg)
Wilfried Mullens et at, Intensive Care Med (2006) 32:1722–1732
IAP range in critical careNormal: 5-7 mmHgElevated: ≥8 mmHg
IAH: ≥ 12mmHg
![Page 27: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/27.jpg)
Prospective cohort, 2006/11~2007/5, CCU, USAAHF: LVEF<30%, PCWP>18 or CVP>8, Total: 40
Goal: PCWP<18, CVP<8, CI>2.2
Wilfried Mullens et at, Intensive Care Med (2006) 32:1722–1732
![Page 28: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/28.jpg)
Retrospective cohort, 1989/1~2006/12, CCU, NetherlandPatient s/p Rt heart catheterization, Total: 2557
Baseline CVP vs. GFR
Kevin Damman et al., J Am Coll Cardiol 2009; 53(7): 582–8
![Page 29: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/29.jpg)
Prospective, 2006/1~2007/6, USA, CCU, Total: 145Inclusion: LVEF<30%, CI<2.4, PCWP>18 or CVP>8
PA catheter goal: PCWP<18, CVP<8, & CI>2.4
Wilfried Mullens et al, J Am Coll Cardiol 2009; 53(7) 589–96
CVP rather than CI ?
![Page 30: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/30.jpg)
Animal study, Dog, 1931, Renal a & v cannulation
F. R. Winton et al, J Physiol 1931; 72: 49–61.
![Page 31: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/31.jpg)
Fluid status evaluation in CRS
Venous congestion may be more important than hypovolemia
脫水 灌水 ??
![Page 32: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/32.jpg)
Other postulated mechanisms of CRS
• Low evidence & inconclusive– Sympathetic overactivity– Adenosine– Vasopressin– Natriuretic peptide– Oxidative injury & endothelial dysfunction
Jeremy S. Bock et al, Circulation. 2010;121:2592-2600.
![Page 33: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/33.jpg)
Sympathetic Overactivity
![Page 34: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/34.jpg)
Gerald F. Dibona et al, Physiol Rev, 1997; 77(1): 75-197
Animal study, Rat, 1980, Renal sympathetic stimulate, Total: 10
![Page 35: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/35.jpg)
Prospective cohort, 2007/6~2008/11, Australia & EuropeanHypertension s/p renal sympathetic denervation, Total: 45
Henry Krum et al, Lancet 2009; 373: 1275–81
Improvement of hypertension
Improvement of renal function??
![Page 36: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/36.jpg)
Pathology
![Page 37: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/37.jpg)
老師 , 第三床 ARF 咧要不要作 Renal biopsy 看一看 ?
第三床不是 第三床不是 Heart failureHeart failure 嗎嗎 ??阿就是阿就是 Pre-renal ARFPre-renal ARF 阿阿 , Biopsy, Biopsy 做什做什
麼麼 ??
![Page 38: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/38.jpg)
Pathology
• Acute heart failure not a traditional indication for renal biopsy
• Case report– The characteristics of acute renal failure in
cardiogenic shock in the elderly– 4 patients with cardiogenic shock and ARF– 1 patient with ATN– 3 patients without pathological change
Durakovi et al, ZFA 1986; 41(5): 301-5
![Page 39: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/39.jpg)
Can we predict who will developed CRS in patients presented with acute cardiac dysfunction?
![Page 40: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/40.jpg)
Known Predictors from Past Observations (I)
WH Tang & W. Mullens. Heart. 2010; 96(4):255-60
![Page 41: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/41.jpg)
Known Predictors from Past Observations (II)
WH Tang & W. Mullens. Heart. 2010; 96(4):255-60
![Page 42: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/42.jpg)
Summary• AKI occurs frequently in AHF (type 1 CRS)
– It is an independent risk factor of worse outcome– However, only very limited prospective
observational studies have addressed the issues
• The mechanism of type 1 CRS remained largely speculative– We have no ideas why his (her) kidney failed– Venous congestion should be kept in mind other
than arterial underfilling
![Page 43: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/43.jpg)
Acute Cardiorenal Syndrome
Epidemiology & Pathophysiology. R3 潘思宇Diagnosis & Management......…... R3 李宗育Volume & Diuretics………………. R3 張凱迪Ultrafiltration………………………. R3 柯雅琳
R5 王介立VS 林水龍
![Page 44: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/44.jpg)
DIAGNOSIS
![Page 45: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/45.jpg)
Back to the Problem…CASE
PRESENTATION
How do we know the sequence?
![Page 46: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/46.jpg)
Time Course of the eGFR
Acute (type 1,3) rather than chronic (type 2,4)…
CASEPRESENTATION
CKD stage 3
AKI
![Page 47: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/47.jpg)
Cause of CKD?CASE
PRESENTATION
12 cm
(Long-standing; microscopicovert)
Other non-DM cause of CKD related to CVD: - Ischemic nephropathy (renovascular disease)
- Malignant hypertension
![Page 48: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/48.jpg)
AKI from Heart?CASE
PRESENTATION
Hypotensive episode?
“No diagnostic criteria = by exclusion”
![Page 49: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/49.jpg)
Typical Acute CRS• Acute heart failure syndrome
• Acute kidney injury
• No evidence of intrinsic kidney disease other than the baseline CKD
So far, has the diagnosis of type 1 cardiorenal syndrome been secured?
![Page 50: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/50.jpg)
Mimickers of Type 1 CRS• NSAIDs causing concurrent heart failure
and vasomotor nephropathy
• Flash pulmonary edema (bilateral renal artery stenosis)
• Hypertensive crisis from identifiable causes (e.g. pheochromocytoma)
(the primary cause is outside the heart)(potentially treatable)
![Page 51: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/51.jpg)
BEDSIDE APPROACH
![Page 52: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/52.jpg)
Bedside Evaluation
Evaluation of perfusion & congestion is equally important in acute renal failure
1Nohria A, et, al. JAMA 2002;287:628-40
![Page 53: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/53.jpg)
MANAGEMENT
![Page 54: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/54.jpg)
Treatment of Type 1 CRS
: Not mentioned
: Not mentioned (unpublished draft)
&
Heart failure guideline
AKI guideline
![Page 55: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/55.jpg)
Overview
ADHF AKI Acute CRS
Drug Therapy …
CPAP ?
Ultrafiltration
![Page 56: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/56.jpg)
Drug Therapy for Acute CRS• Traditional agents for AHF
– Oxygen– Morphine– Vasodilators– Inotropopic agents– Vasopressin antagonists– Loop diuretics
• Investigational agents with specific renal effect
Renal effect?
![Page 57: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/57.jpg)
Vasodilator therapy
• Nitroglycerin– Effect on Renal Function ?
Lagrand WK, et al. Curr Probl Cardiol. 2009;34(8):330-349.
![Page 58: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/58.jpg)
• Sodium nitroprusside– Improved outcomes and stable kidney function
• Nesiritide– Synthetic human B type natriuretic peptide:
potent vasodilator– Increased the risk of worsening renal function ?
Vasodilator therapy
Mullens W, et al. J Am Coll Cardiol. 2008;52(3):200-207.
Sackner-Bernstein JD, et al. Circulation 2005; 111: 1487-1491
![Page 59: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/59.jpg)
Comparison between clinical effects of intravenous vasodilators in the treatment of heart failure
Elkayam, U., M. Janmohamed, et al. (2008). "Vasodilators in the management of acute heart failure." Crit Care Med 36(1 Suppl): S95-105.
Elkayam, U., et al. (2008). Crit Care Med 36(1 Suppl): S95-105
Variables Nitroprusside Nitroglycerine Nesiritide
Clinical studies -- + +++
Hemodynamic effect +++ +++ +++
Tolerance -- ++ --
Need for dose titration
+++ +++ --
Effect on coronary flow Myocardial ischemia NAEffect of urine output NA NA +/-Effect on neurohormones
+ + +
![Page 60: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/60.jpg)
Mullens W, et al. J Am Coll Cardiol. 2008;52(3):200-207.
Sodium nitroprusside for advanced low-output heart failure. retrospective, 2000~2005, USA, ADHF: CI<2
L/min/m2,Total: 175, Scre: 1.3~1.5 mg/dL
![Page 61: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/61.jpg)
Sackner-Bernstein JD., et al. Circulation 2005; 111: 1487-1491
The use of nesiritide for ADHF did not avoid type 1 CRS and increased the risk of worsening kidney function, as well as mortality, in the active treatment groups
Incidence of Worsening Renal Function in studies ofNesiritide for ADHF. Meta-analysis of 5 randomized double-blind controlled trials , WRF: SCre > 0.5mg/dL, USA, Total: 1269
![Page 62: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/62.jpg)
Witteles RM, et al. J Am Coll Cardiol. 2007 Nov 6;50(19):1835-40.
No significant difference was observed in the primary end point of worsenedrenal function (increase in serum creatinine 20%)
Impact of Nesiritide on renal function. Separate randomized double-blind controlled trials , Scre: 1.82: 1.86mg/dL, USA, Total: 75
![Page 63: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/63.jpg)
Inotropic Agent: Levosimendan
• Lusitropic activity(calcium sensitizer) Improves hemodynamics and renal perfusion compared with dobutamine but not comfirmed in SURVIVE study
Yilmaz MB, et al. Cardiovasc Drugs Ther. 2007;21(6):431-435.
![Page 64: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/64.jpg)
Levosimendan: Improves hemodynamics and renal perfusion
Yilmaz MB, et al. Cardiovasc Drugs Ther. 2007;21(6):431-435.
P< 0.001
P= 0.008
P< 0.001
P > 0.05 for all
![Page 65: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/65.jpg)
Mebazaa A. et al,. SURVIVE Investigators. JAMA. 297(17):1883-91, 2007 May 2.
Levosimendan Dobutamine
Cox Proportional Hazards P = 0.04
Time Since Start of Study Drug Infusion, d
Effect of Dobutamine and Levosimendan Treatment on All-Cause Mortality -- The SURVIVE Trial: randomized, double-blind trial, 2003~2004, LVEF: 24%,Total: 1327, Scre: >2.5 mg/Dl(n=87)
0 30 60 90 120 150 180
1.0
0.8
0.6
0.4
0.2
0
![Page 66: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/66.jpg)
Kellum JA, et al. Crit. Care Med 2001;29: 1526-1531
The use of low-dose dopamine for the treatment or prevention of acute renal failure cannot be justified on the basis of available evidence and should be eliminated from routineclinical use.
![Page 67: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/67.jpg)
Vasopressin Receptor Antagonist
• Increased renal free water clearance and improvement in hyponatremia and weight loss without survival benefit
Konstam MA, et al. the EVEREST Outcome Trial. JAMA 2007; 297: 1319-1331
![Page 68: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/68.jpg)
Vasopressin Receptor Antagonist
Sanghi P, et al .Eur Heart J 2005;26:538-43.
Atrial underfilling
BaroreceptorsLeft atriumCarotid sinusAortic arch
Hyperosmolality
Osmoreceptors
Vascular smooth muscleV1 a receptors
Collecting duct of kidneyV2 receptors
Vasocontriction Water re-absorption
![Page 69: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/69.jpg)
Profile of AVP receptor antagonists
Cleve Clin J Med. 2006 Sep;73 Suppl 3:S24-33.
Conivaptan (YM-087)
Tolvaptan(OPC-41061)
Receptor(s) V1A/ V2 V2
Admin. route Intravenous Oral
Urine volume
Urine Osmolality
Sodium excretion in 24hours
![Page 70: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/70.jpg)
Acute hemodynamic effects of conivaptan
Udelson JE, et al. Circulation 2001;104:2417-23.
Placebo 10 mg 20 mg Conivaptan 40 mg
Time (h)
0 1 2 3 4 5 6 7 8 9 10 11 12
300
100
50
0
-50
-100
250
200
150
![Page 71: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/71.jpg)
Konstam MA, et al.JAMA 2007; 297: 1319-1331
Log-Pank Test: P = 0.76Peto-Peto-Wilcoxaon Test: P = 0.68Stratified Peto-Peto-Wilcoxon Test: P= 0.68
All Cause Motality
Months of Study
All-Cause Mortality and Cardiovascular Mortality or Hospitalization —Tolvaptan (The EVEREST Outcome Trial): randomized, double-blind trial, 2003~2006, LVEF: 27.5%,Total: 4133, Scre: >1.3 mg/dl(n=827)
0 3 6 9 12 15 18 21 24
1.0
0.9
0.8
0.7
0.6
0.5 0.4 0.3
0.2
0.1
0
![Page 72: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/72.jpg)
Investigational agents: Adenosine A1−Receptor Antagonist
![Page 73: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/73.jpg)
Renal effects of Adenosine A1 receptor Antagonists in Congestive heart failure
Gottlieb SS. Drugs 2001;61:1387-93.
Tubule LumenIncreased NaCl delivery Increased adenosine (perhaps
from ATP needed for active transport)
Adenosine A1 receptor
Vasocontriction
Afferent arteriole
Adenosine A1 receptor AntagonistBG 9719KW3902 (Rolofylline)
![Page 74: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/74.jpg)
Adenosine Antagonistgs
Stephen S. Gottlieb, Circulation. 2002;105:1348-1353
BG9719 + Furosemide
BG9719
Urine Volume (ml)0~8 hours(Day 1 - Baseline
BG9719 Dose (mcg/ml)-0.5 0 0.5 1 1.5 2 2,5 3
2000
1500
1000
500
0
![Page 75: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/75.jpg)
Adenosine Antagonistgs
Stephen S. Gottlieb, Circulation. 2002;105:1348-1353
GFR(% change)(1~8 hours)
Urine Output (ml)(0~8 hours, Day 1 - Baseline)
BG9719
PlaceboFurosemide Alone
BG9719 + Furosemide
0 500 1000 1500 2000 2500
15
5
-5
-15
-25
![Page 76: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/76.jpg)
Barry M. Massie, et al. N Engl J Med 2010; 363:1419-1428
Placebo
Rolofylline
Hazard ration: 1.03 (95% CI, 0.82-1.28)P = 0.82
Day
Rolofylline (KW3902), an Adenosine A1 receptor antagonist in acute heart failure with impaired renal function (PROTECT-1): randomized, double-blind trial, LVEF: 32%,Total: 2033, Ccr: 50.4~51 ml/min
0 30 60 90 120 150 180
35
30
25
20
15
10
5
0
![Page 77: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/77.jpg)
Major Ongoing Clinical Trials of Renal-Sparing Treatment Strategies
Drug Trial acronym Phase Sample size
Natriuretic peptides Nesiritide
CD-NPASCEND-HF
CONDITION-HFIVII
7000380
Vasopression receptor antagonist Tolvaptan Conivaptan Lixivaptan
EVERESTCONVERT-HF
BALANCE
IIIIIIIII
3600105650
Adenosine A1 receptor antagonists Rolofylline SLV320 BG-9928
PROECT1&2RENO-DEFEND 1
POSEIDON/TRIDENT
IIIII
II/III
2000500
300/900
Standard treatment Loop diuretics Ultrafiltration
DOSE-AHFCARRESS
IVIV
300200
![Page 78: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/78.jpg)
Summary• There is nothing specific for the diagnosis
of acute cardiorenal syndrome– Follow the principle of diagnosis of AKI
• No definite pharmacological therapy could be recommended for the acute cardiorenal syndrome– Follow the principle of therapy of AHF
![Page 79: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/79.jpg)
Acute Cardiorenal Syndrome
Epidemiology & Pathophysiology. R3 潘思宇Diagnosis & Management......…... R3 李宗育Volume & Diuretics………………. R3 張凱迪Ultrafiltration………………………. R3 柯雅琳
R5 王介立VS 林水龍
![Page 80: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/80.jpg)
How to Measure the Fluid Status?
![Page 81: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/81.jpg)
Possible Methods to Evaluate Fluid Status
• History and Physical Examination• Body Weight• JVP/CVP/PCWP• Pulse wave variation• Urine Sodium• Natriuretic peptide• CXR• Thoracic Ultrasound• Vena Cava Ultrasound• Initial Distribution Volume of Glucose• Bioimpedance spectrography• ……
![Page 82: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/82.jpg)
In our daily practice……
Toshiba.com
Library and Archives Canada
![Page 83: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/83.jpg)
Wang CS, JAMA 2005;294:1944-1956
Evaluation about fluid status: History takingMeta-analysis of 18 studies during 1966~2005
FindingFinding SensitivitySensitivity SpecificitySpecificity Positive Positive LRLR
Negative Negative LRLR
Symptoms
Paroxysmal nocturnal dyspnea 0.41 0.84 2.6 0.70
Orthopnea 0.50 0.77 2.2 0.65
Edema 0.51 0.76 2.1 0.64
Dyspnea on exertion 0.84 0.34 1.3 0.48
Fatigue and weight gain 0.31 0.70 1.0 0.99
Cough 0.36 0.61 0.93 1.0
![Page 84: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/84.jpg)
FindingFinding SensitivitySensitivity SpecificitySpecificity Positive Positive LRLR
Negative Negative LRLR
Physical examinationThird heart sound 0.13 0.99 11 0.88
Abdominal jugular reflux 0.24 0.96 6.1 0.79
Jugular vein engorgement 0.39 0.92 5.1 0.66
Rales 0.66 0.78 2.8 0.51
Any murmur 0.27 0.90 2.6 0.81
Lower extremit edema 0.50 0.78 2.3 0.64
SBP<100mmHg 0.06 0.97 2.0 0.97
Fourth heart sound 0.05 0.97 1.6 0.98
SBP>150 0.28 0.73 1.0 0.99
Wheezing 0.22 0.58 0.52 1.3
Ascites 0.01 0.97 0.33 1.0
Wang CS, JAMA 2005;294:1944-1956
Evaluation about fluid status: Physical examinationMeta-analysis of 18 studies during 1966~2005
![Page 85: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/85.jpg)
Body Weight
Chaudhry SI, et al, Circulation 2007;116:1549–1554
Days before admission
![Page 86: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/86.jpg)
Chest Radiography
10 ± 4 22 ± 4 34 ± 4
Cardiomegaly 87 98 100
Redistribution 26 40 66
Interstitial edema 16 47 61
Peribronchial cuffing 10 40 22
Hilar haziness 16 40 44
Kerley B line 16 40 39Chakko S, et al, Am J Med 1991;90:353–359
PCWPCXR finding (%)
![Page 87: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/87.jpg)
Chest Radiography and Diagnosis of CHF
Acute Decompensated Heart Failure National Registry (ADHERE)
(~2004/7)
Patients discharge with diagnosis of CHF
Sean P. Collins et.al, Ann Emerg Med. 2006;47:13-18
**CXR negative rate: 18.7%
![Page 88: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/88.jpg)
Chest Radiography
Limitation
• Technique
• Abnormalities lag the clinical appearance by hours
• Unreliable sensitivity, specificity and predictive value in Chronic HF patients
![Page 89: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/89.jpg)
Natriuretic Peptides
• BNP
• NT-pro-BNP
Marc Vanderheyden, et al, J. Am. Coll. Cardiol. 2004;44;2349-2354
![Page 90: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/90.jpg)
NP level: Rapid Response to ↓PCWP
Kazanegra R, et al. J Card Fail 2001;7:21–29
![Page 91: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/91.jpg)
Why NP Level did not Decline Despite Effective Treatment?
1. Acute cardiorenal syndrome renal insufficiency
2. Mobilization of third-space fluid rather than lowering cardiac filling pressure
3. High optivolemic BNP level
Maisel A , et al, Eur J Heart Fail, 2008;10:824-39
![Page 92: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/92.jpg)
NP level: “Wet” versus “Optivolaemic”BNPpg/mL
t
Wet BNP levels
Optivolemic (dry) BNP levels
DecongestionDecongestionDecongestionDecongestion
Maisel A , et al, Eur J Heart Fail, 2008;10:824-39
?
![Page 93: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/93.jpg)
Thoracic Ultrasound
• B-lines: – thickened interstitia – fluid-filled alveoli
![Page 94: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/94.jpg)
Thoracic Ultrasound
Liteplo AS. et al, Acad Emerg Med, 2009;16:201-210
Threshold for a Positive Test Sensitivity Specificity LR+ LR-
8-zone Totally positive (4-B) 0.23 1.00 Infinite 0.78
8-zone Positive (> 2-B) 0.58 0.85 3.88 0.50
2-Zone (4 and 8) 0.53 0.89 4.73 0.53
![Page 95: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/95.jpg)
Thoracic Ultrasound
Positive ultrasound lung scans in the 11 individualizeable thoracic areas before and after treatment in 70 ADHF patients
Thoracic area Before tx After tx P
Giovanni Volpicelli, et.al, Am J Emerg Med, 2008;26:585-591
![Page 96: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/96.jpg)
• Predicting right atriam pressure > 10mmHg
IVC Respiratory Variation Ultrasound
%Collapse % sen. % spe.
20 38 100
40 74 91
50 87 82
60 94 44
80 98 14
Kircher B, et al, J,Am J Cardiol. 1990;66(4):493-496
![Page 97: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/97.jpg)
IVC Respiratory Variation Ultrasound
IVC Respiratory Variation:
• CHF: 9.6% vs non-CHF: 46%
David J. Blehar, et.al, Am J Emerg Med, 2009; 27: 71-75
1
0.4
0.8
0.6
0.2
0.2
1-specificity0.80.60.4
Sens
itivi
ty
**Cutoff value: 15% -Sensitivity: 93% -Specificity: 84%
![Page 98: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/98.jpg)
Initial Distribution Volume of Glucose
•
Gabbanelli V, et.al, Intensive care medicine 2004;30:2067-73.
![Page 99: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/99.jpg)
Bioimpedance Spectroscopy
Calculate the proportion of total body water, fat, and muscle
Limitation:1. Only validated in chronic HD patients
2. Interfere by other body monitor
Wabel P, et al. Nephrol Dial Transplant 2008;23:2965-71
![Page 100: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/100.jpg)
SummaryMeasurements Advantages Limitations
History and Physical Examination Rapid assessment Low sensitivities
Body WeightSimple measurement May not represent intravacular
volume change
JVP/CVP/PCWP Good sensitivity and specificity Need invasive method
Pulse wave variation Rapid assessment Invasive arterial cannulation
Natriuretic peptidePredict outcomes Less specificity in certain
conditions (CKD, obesity…)
CXRObjectively represent pulmonary congestion
Not enough sensitive or specific
Thoracic UltrasoundRapid and easy to use at bedside.
Evolving technology; requires training
Vena Cava UltrasoundRapid and easy to use at bedside
Evolving technology; requires training
Initial Distribution Volume of Glucose
Rapid and easy to use at bedside
Cannot represent extravascular volume
Bioimpedance spectrographyNeed specialized equipment Evolving technology; may not
represent preload
![Page 101: 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.](https://reader036.fdocuments.net/reader036/viewer/2022081416/56649e695503460f94b66ccd/html5/thumbnails/101.jpg)
Gheorghiade M, et al. European Journal of Heart Failure 2010;12:423-33.