berlene v the role of pd in cardio renal syndrome

8/18/2019 Berlene v the Role of PD in Cardio Renal Syndrome

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The Role of PD in

Cardio-RenalSyndromeBerlene Villanueva, R.N., B.N.,CNeph(c) – Manitoba Health


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Epidemiology

Heart failure is a common chroniccondition affecting 1% of adultpopulation in Canada and is the

common cause of hospitalization inthose aged 65 and above (Heart and StrokeFoundation)

Direct and indirect costs wereestimated at $18.4 billion in 1998(Canadian Public Health Association 1998)


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Number of Hospitalizations for CHF (actual andprojected) for Canada 1980-2025

Heart and Stroke Foundation,1999


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One third to one half of patients withheart failure develop renalinsufficiency

AKI may further complicate theseadmissions resulting in: an increase inlength of stay, greater likelihood for

hospital readmission and a highermortality rate (Forman DE, Bulter J., Wang Y. et.al. J Am Coll Cardiol 2004; 147:331-338)


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Pathophysiology

Heart failure characterized by sodium andH20 retention by kidneys

HF impairs sufficient blood flow to organs,kidneys retain salt and water that leads tocongestion and clinical s+s of HF

Understanding the cardiorenal axis

(relationship btw the heart and kidney)

Successfully managing HF lies in navigatingbtw fluid overload and deteriorating renal

function


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What is Cardio-

Renal Syndrome?


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Definition of Cardio-Renal

Syndrome

Pathophysiologic condition in whichcombined cardiac and renaldysfunction amplifies progression offailure of the individual organ to leadto astounding morbidity and mortality(Eur Heart J 2005:26:11)

At its extreme, cardio-dsyregulationleads to what is termed “cardiorenalsyndrome”; in which therapy to relievecongestive symptoms of HF is limitedby further decline in renal function(NHLBI Working Group April30,2005)


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Definition of Cardio-Renal

Syndrome

2008 Ronco: attempted to furtherdefine the syndrome by including avariety of acute or chronic conditions,

where the primary failing organ can beeither the heart or the kidney


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Cardio-Renal Syndrome

Classification (ADQI)

The Cardiorenal Syndrome (CRS)was officially defined at a consensusconference of the Acute DialysisQuality Initiative in 2009

Conference defined 5 forms of heart-kidney interaction

Recognition that communicationbetween the heart and kidneys occursthrough a variety of pathways


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Cardiorenal Type I:

Acute cardiorenal syndrome: Acute heartfailure is directly associated with acute kidneyfailure (AKI) Ronco, C. et al. J AM Coll Cardiol 2008;52:1527-1539


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Cardiorenal Type II:

Ronco, C. et al. J AM Coll Cardiol 2008;52:1527-1539

Chronic cardiorenal syndrome: Chronic heartfailure is associated with chronic kidneydisease (CKD)


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Cardiorenal Type III:


Acute renocardiac syndrome: Acute kidneyinjury is associated with acute heart failure


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Cardiorenal Type IV:


Chronic renocardiac syndrome: Chronic kidney

disease primarily leads to chronic heart failure


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Where does PD fit in?

Role of PD in management of cardio-renal syndrome has not been formallyevaluated in clinical trials

Literature is restricted


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Where does PD fit in?

Most individuals with CRS have beenthrough numerous interventions:diuretics, drugs, extracoporeal

ultrafiltration

Symptoms can be attributed to theretention of salt and water

Most are refractory to diuretic therapy,and often develop hyponatremia and

hyperkalemia


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Cardiorenal patients

Often suffer great morbidity, largelyfrom repeated hospitalizations relatedto recurrent worsening of volume

overload

Extracorporeal ultrafiltration, suffersfrom several limitations: requires ptsto return to health-care facilities andfluid removal can be complicated by

hypotension


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Change in Function Status with

use of Peritoneal Dialysis

Mehrotra, R. and Kathuria, P. Kidney International 2006;70:S67-S71


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Effect of PD on Hospitalizations

Mehrotra, R. and Kathuria, P. Kidney International 2006;70:S67-S71


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Potential Roles of Peritoneal Ultrafiltration in

Patients with Cardiorenal Syndrome

Restore diuretic responsiveness

Bridge therapy (eg. Valverepair/replacement or cardiactransplantation)

Palliative therapy

Improve symptoms and exercise tolerance

Preserve residual renal function

Reduce hospitalizations

Improve quality of life


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Why PD?

Home based, long term therapy is usually

well established in many centers

Simple machinery, less use of hospitalresources

Associated with preservation of renalfunction, gentle continuous ultrafiltration,

hemodynamic stability, better middle-molecule clearance, sodium sieving withmaintenance of normonatremia, and less

inflammation (Krishnan,A. et. Al, Advances in Peritoneal

Dialysis 2007;23:82-89)


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St.Boniface Hospital History

Serve as 1 of 2 centers, located inWinnipeg that offer PD to theresidents of Manitoba and

Northwestern Ontario

Current PD population: 180 pts

Current Cardiorenal: 8 pts

Total Cardiorenal: 12 pts


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Referral

PD Assessment

PD Catheter Insertion

Training

Evaluation/Clinic Follow-Up


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Our Goals:

Reduce HF risk factors

Reduce HF symptoms

Reduce hospitalizations

Improve quality of life

Prolong survival


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Referral Process

Depends on cardiology/nephrology tomake an accurate and timelydiagnosis

Refer patients at a higher risk so thattreatment can be initiated


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Assessments

Modified cardiorenal

All patients and/ordesignated familymust be able tomanage PD cath

Assisted PD programnot eligible to drain

out ascites forpatients

Discussion of differentstages of intervention

General PD

May be eligible for Assisted PDprogram


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Stages of Intervention

Stage 1 – Ascities drain out only

Stage 2 – Single night time exchangewith icodextran

Stage 3 – 1-2 dextrose twin bags forvolume management

Stage 4 – Full CAPD


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PD cath placement for drainage

of ascites in non ESRD patients

Criteria that need to be met:

A. Patient is on maximal diuretics anddiuretic resistant AND/OR

B. Frequent requirement for paracentesis (atleast twice monthly) AND/OR

C. Frequent hospitalizations for acutedecompensated congestive heart failure (atleast 3 times within 6 months)

Nephrologist who is assessing the patientfor PD catheter will decide if criteria arebeing met


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Training for Cardiorenal

Dependent on stage of interventionrequired

Each stage has separate training

requirements

Change in training manuals/forms


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Training for Cardiorenal

Physician:

Defines quantity of fluid to be removed

Details/clarifies criteria for adjusting fluidremoval

Establishes fluid restriction

Nurse:

Enforces requirement for that stage

Establishes recording of intake/output

Monitoring of patient

Basic troubleshooting

St B if C di l


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St. Boniface – Cardio-renalpopulation

0 2 4 6

Stage 1

Stage 2

Stage 3

Stage 4

Ful l PD

1-2 Bags

Icodextran

Ascites


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Timeline/Progression of

Stages

0 10 20 30 40 50 60

Months

TH

JH

MCM

CB

SMPS

MT

RT

SR(d)

IT (d)

GF(d)

CR (d)

C a r d i o r e n a

l P a t i e n t s

Stage 1

Stage 2

Stage 3

Stage 4


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Evaluation/Follow up

Any patient that requires even onedaily exchange will be followed in thePD program as any other PD patient

Clinic: monitor GFR

Communication with Heart Failure

clinic: to assist in determining whetherpt requires different stage ofintervention


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Pitfalls, Challenges and

Practicality

No established guidelines/algorithm

Draining issue/blocked catheter vs. noascities drainage

Maintaing bp’s

Infection


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Effectiveness

Did we accomplish our goals?

Majority of patients report decrease inHF symptoms, and improved quality

of life

Since commencing PD, only 2 of 8 pts

have required hospitalization (1 forICD replacement)


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Future prospects at SBH

Looking at the development of aCardiorenal Clinic

New initiative to capture patients who

fall into this particular subset –primarily Type IV CRS

Benefits: Coordination of care,Identification of risk, Facilitatetreatment if indicated


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General Future prospects

Large trials with long term follow up tolook at the effects of PD onprogression of heart failure

Studies to compare PD with standardtherapy to demonstrate survivalbenefits, morbidity and costs


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Summary

Cardiorenal syndrome has complex

pathophysiology

Combination of renal insufficiency and

heart failure make management achallenge, associated with poorprognosis

PD can be used to alleviate somesymptoms of HF, but mainly used as apalliative focus


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The End

berlene v the role of pd in cardio renal syndrome

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