crs harkit 2011 prsnt

8/7/2019 CRS HARKIT 2011 prsnt

1/53

Clinical Cardiology ConferenceClinical Cardiology Conference

Sabtu, 22 Januari 2011Sabtu, 22 Januari 2011CARDIO RENALCARDIO RENALsyndromesyndrome

Rully RoesliRully Roesli.Bag I Peny Dalam.Bag I Peny Dalam-FK UNPAD BANDUNG-FK UNPAD BANDUNG


2/53

Exp Clin Cardiol. 2008 Winter; 13(4): 165170.

PMCID: PMC2663478

Copyright 2008, Pulsus Group Inc. All rights reserved

Clinical Cardiology: Review

Cardiorenal syndromeCardiorenal syndrome: A literature review: A literature review

aharjan, MD, Bismita Dhakal, PharmD, and Rohit R Aro

Exp Clin Cardiol. 2008

Winter; 13(4): 165170.

PMCID: PMC2663478
http://www.ncbi.nlm.nih.gov/pmc/about/copyright.htmlhttp://www.ncbi.nlm.nih.gov/pmc/about/copyright.htmlhttp://www.ncbi.nlm.nih.gov/pmc/about/copyright.html


3/53


4/53

ORGAN CROSS-TALKORGAN CROSS-TALKbetween thebetween the KIDNEYKIDNEYand theand the HEARTHEART


5/53


6/53

Your Topic Goes Here


7/53

43,6 % of dall deaths in ESRD patients is due to Cardiac causes43,6 % of dall deaths in ESRD patients is due to Cardiac causes

It is 10 20 times more common when compare to generalIt is 10 20 times more common when compare to generalpopulationpopulation

LVH and CAD are found in 75% ESRD patientsLVH and CAD are found in 75% ESRD patients

Up to 30 % of patients with heart failureUp to 30 % of patients with heart failurehad worsening renal functionhad worsening renal function

Breaking NEWS

Breaking NewsBreaking News

Among 1004 HF patients studied, WRF developed in 27 %


8/53

How do we know there is aHow do we know there is aCARDIOCARDIO ~~ RENALRENALconspiration ?conspiration ?J Hypertension, November 2003


9/53

How do we know there is aHow do we know there is aCARDIOCARDIO ~~ RENALRENALconspiration ?conspiration ?


10/53

DEFINITION & CLASSIFICATION

Nephrol Dial Transplant (2010) ; 25 : 1416 - 1420


11/53

TheTheCardiologistCardiologist

TheTheNephrologistNephrologist

:what is :what isCARDIO RENALCARDIO RENALsyndrome ?syndrome ?Paganini :Paganini : if I could answer that with a short, precise definition,if I could answer that with a short, precise definition,

I would probably win some sort of price I would probably win some sort of price

It is something happens with

your kidney when you have CVDor it occurs with CHF

It is something happens when you

have CHF or CVD and itsassociated with renal dysfunction

It is not only aIt is not only amatter ofmatter ofVOLUME OVERLOADVOLUME OVERLOADAcceleratedAccelerated

atherosclerosisatherosclerosisMyocardial angiopathyMyocardial angiopathy

Coronary artery stenosisCoronary artery stenosisLeft VentricularLeft Ventricular

HypertrophyHypertrophy


12/53

thetheCARDIOCARDIO ~~ RENALRENAL -CROSS TALK-CROSS TALK


13/53

DEFINISIDEFINISI


14/53

KLASIFIKASIKLASIFIKASI


15/53

PATHOPHYSIOLOGYPATHOPHYSIOLOGY


16/53


17/53

VOLUMEOVERLOAD

INCREASEDCOP

INCREASEDPERIPHERAL

RESISTANCE

INCREASEDBP

PRESSURENATRIURESIS

DIURESIS

NORMALIZEBODY VOLUME

HEARTHEARTFAILUREFAILURE

NORMALNORMALKIDNEYKIDNEY

TOTAL BODY AUTOREGULATIONTOTAL BODY AUTOREGULATION(GUYTON)(GUYTON)

normalnormalphysiologyphysiology

thethe KIDNEYKIDNEYhelpshelps

thethe HEARTHEARTNORMAL

BP

NORMALIZECOP

NORMALIZEPERIPHERAL

RESISTANCE

CARDIO RENAL INTERACTION

poorperfusion

INTER ORGAN COMMUNICATIONINTER ORGAN COMMUNICATION


18/53

What happens if the HEART & the KIDNEYdidnt communicate well ?

Cardio Renal SyndromeCardio Renal Syndrome


19/53

poorperfusion

VOLUMEOVERLOAD

LOWCOP

R A SALDOSTERONE

SNS ACTIVITYNO-ROS dysbalance

Inflammatory mediators

INCREASEDBP


Clamping downClamping downSodium retentionSodium retention

RENALRENALFAILUREFAILURE

INFLAMMATIONINFLAMMATION

CARDIO-RENAL SYNDROMECARDIO-RENAL SYNDROME(GUYTON REVISITED)(GUYTON REVISITED)

thethe KIDNEYKIDNEY&&

thethe HEARTHEART

reciprocalreciprocalHELPHELP

oror

reciprocalreciprocalDAMAGEDAMAGE

ANURIOLIGOURI

CARDIO RENAL CONSPIRATION


20/53

Since increased activity of the renin-angiotensin system , oxidative stress,Inflammation, and increased activity of the sympathetic nervous system seem

To be the cornerstone of the pathophysiology in combined chronic renal diseaseand heart failure


21/53

CLINICAL SIGNSCLINICAL SIGNS


22/53

Risk Factors-Old age

-Low Ejection Fraction

-Elevated creatinine level-Low Systolic Blood Pressure

-Diabetes Mellitus-Hypertension

-Use of antiplatelet drugs, diuretics,or beta-blockers

CLINICAL SIGNS ofCLINICAL SIGNS ofCARDIOCARDIO ~~ RENALRENALSYNDROMESYNDROMEpatient withpatient with

ADHF = Acute Decompensated Heart FailureADHF = Acute Decompensated Heart FailureCHF = Congestive Heart FailureCHF = Congestive Heart Failure

worsen of RENAL FUNCTIONworsen of RENAL FUNCTION

VOLUME OVERLOADVOLUME OVERLOAD

RESISTANCE TO DIURETICSRESISTANCE TO DIURETICS

Hyper or hypo- kalemiaHypomagnesemia

Hyponatremia

MARKERS:

CreatinineCystatin

NGAL

C O S O


23/53

poorperfusion

VOLUMEOVERLOAD

LOWCOP

INCREASEDBP




CARDIO-RENAL SYNDROMECARDIO-RENAL SYNDROMETARGET OF TREATMENTTARGET OF TREATMENT

ANURIOLIGOURI

(VOLUME OVERLOAD)


R A SALDOSTERONE

SNS ACTIVITYNO-ROS dysbalance

ULTRAFILTRATIONULTRAFILTRATIONDIURETICSDIURETICS

ANTI-INFLAMMATIONANTI-INFLAMMATION

ANTI- RAASANTI- RAAS

CARDIO RENAL SYNDROME


24/53

poorperfusion

VOLUMEOVERLOAD

LOWCOP

INCREASEDBP




CARDIO-RENAL SYNDROMECARDIO-RENAL SYNDROMETARGET OF TREATMENTTARGET OF TREATMENT

ANURIOLIGOURI

(VOLUME OVERLOAD)


R A SALDOSTERONESNS ACTIVITY

NO-ROS dysbalance

DIURETICSDIURETICS ULTRAFILTRATIONULTRAFILTRATION

ANTI-INFLAMMATIONANTI-INFLAMMATION

ANTI- RAASANTI- RAAS


25/53

When HEART & the KIDNEYdidnt communicate well

Cardio Renal SyndromeCardio Renal Syndrome


26/53

INFLAMMATIONINFLAMMATION~ is the~ is theCARDIOCARDIO ~~ RENALRENALconspirationconspiration


27/53

other CONSPIRATIONother CONSPIRATION


28/53

MANAGEMENTMANAGEMENT


29/53


30/53

Managing cardiorenal syndrome:Managing cardiorenal syndrome:

Practical recommendations.Practical recommendations.

ict fluid and sodium intake

ase furosemide dose

ontinuous intravenous furosemide

hiazides or metolazoneenoprotective dopamine at 2 3 mcg/kg/min

notropeor vasodilator (according to systolic blood

ultrafiltration

t intra-aortic balloon pump

t another device

TARGET OF TREATMENTTARGET OF TREATMENT


31/53

TARGET OF TREATMENTTARGET OF TREATMENTVOLUME OVERLOADVOLUME OVERLOAD

DIURETICSDIURETICS

LOOP DIURETICSLOOP DIURETICS(furosemide)(furosemide)

ORALORAL

DRIPDRIP(recommended)(recommended)

BOLUSBOLUS

Diuretic ResistanceDiuretic Resistance-Inadequate doseInadequate dose-Excess sodiumExcess sodium

-Delayed absorptionDelayed absorption-NSAIDNSAID

-Renal or Heart failureRenal or Heart failure

THIAZIDESTHIAZIDES(HCT)(HCT)

LFG < 30 cc/mnt

Note : diuretics therapy can worsen renal functionNote : diuretics therapy can worsen renal function

Change to other LDChange to other LD(bumetanide/torsemide)(bumetanide/torsemide)

Use -type Natriuretic PeptideUse -type Natriuretic Peptide(BNP=nesiritides)(BNP=nesiritides)

Increased oncotic pressure with :Albumin/Mannitol/Colloid

Low-dose Dopamin:Not recommended

Effect :Effect :-reduce pre/after-loadreduce pre/after-load-natriuresis/diuresisnatriuresis/diuresis

-suppress norepinephrine, endotelin,suppress norepinephrine, endotelin,and aldosteroneand aldosterone

may increased risk of renal failureIn heart failure patients

NEED MORE INVESTIGATION



32/53

TARGET OF TREATMENTTARGET OF TREATMENTULTRAFILTRATIONULTRAFILTRATION

SEVERE VOLUME OVERLOADSEVERE VOLUME OVERLOAD

iv DIURETICSiv DIURETICSDIURETIC

RESISTANCE ULTRAFILTRATIONULTRAFILTRATION

CRRTCRRT SLEDDSLEDD

The UNLOAD trial : early UFSCUFSCUF

Diuretic Dose


33/53

Diuretic Dose

. :according to the renal function in heart failure patients IV intra

Diuretic CrCl CrCl CrCl75/ml min /ml min /ml minFurosemide 80 160 160 200 40 80 40 20 then 40 10 then 2010

Bumetanide 4 8 8 10 1 2 1 1 then 2 .0 5 then 1 .0 5Torsemide 20 50 50 100 10 20 20 10 then 205 then 10 5

Moderate renal Severe renal Heart FailureInsufficiency Insufficiency

Maximal IV dose (mg)IV

LoadingDose(mg)

Infusion rate (mg/hr)



34/53

TARGET OF TREATMENTTARGET OF TREATMENTINREASED RAASINREASED RAAS

Use of ACE-I OR ARBUse of ACE-I OR ARB

Start with low dosePatient not dehydrated

Avoid using NSAID

When using of ACE-I OR ARB beware of : increased creatinin and potassiumWhen using of ACE-I OR ARB beware of : increased creatinin and potassium

BETTER OUTCOMEBETTER OUTCOME(SOLVD,PRIME-2,CONSENSUS,ELITE)(SOLVD,PRIME-2,CONSENSUS,ELITE)

increasedincreasedpotassiumpotassium

increasedincreasedcreatininecreatinine

Combination withCombination with

CCBCCB

Combination withCombination with

DIURETICSDIURETICS

If contra-If contra-

indicatedindicated

Hydralazine/Hydralazine/Isosorbid-dinitratesIsosorbid-dinitrates

ISORDILISORDIL



35/53

TARGET OF TREATMENTTARGET OF TREATMENTFUTURE DRUGSFUTURE DRUGS

Arginine Vasopressin Receptor Antagonists(Conivaptan or Tolvaptan)

- antagonist the arginine vasopressin secreted by pituitary gland- results in diuresis and retention of electrolytes

Adenosine A1 Receptor Antagonists(Conivaptan or Tolvaptan)

- antagonist plasma adenosine

- results in diuresis and natriuresis


36/53

TREATMENTTREATMENT

RENAL SUPPORTRENAL SUPPORT


37/53

NICETOK

NOW

NICETOK

NOW

( WHOM TO CONSULT ? )


38/53

HYBRID DIALYSIS


39/53


40/53


41/53


42/53


43/53

HYBRID DIALYSIS


44/53

IHDIHD CRRTCRRTIHD SLED CRRT

Td (jam) 4-5 6 12 24

Qb (cc/m) 200-300 100-150 100-150

Qd (cc/m) 500 300 0

UF (/jam) Cepat

(4-5 jam)

Sedang

(6-12 jam)

Lambat

( 24 jam)

Hybrid DialysisHybrid Dialysis


45/53

Pilihan dialisis:baru


46/53

HFRHFR HDFHDF


47/53

Hemo-Hemo-diafiltrationdiafiltration

ReinfusionReinfusion(HFR)(HFR)

Qbi

Qbo

Qdi

Qdo

Out

QR

Convection

Diffusion

QR = Out

Weight

Adsorption byhydrophobic

resin

HFR is a dialytic methodwhich uses convection,

diffusion and adsorption atthe same time

The dialyzer is divided intotwo compartments, one for

the convective and one forthe diffusive process


48/53

post - diluitionpost - diluition pre - dilutionpre - dilution

Stage 1Stage 1

HDF post - dilutionHDF post - dilutionStage 2Stage 2

HDF pre - dilutionHDF pre - dilution

FlowFlow

ufuf11 ufuf22

BloodBlood

inin

BloodBlood

outout

Substitution fluidSubstitution fluid

inin

DialysateDialysate

inin

FlowFlow

DialysateDialysate

outout

++

How to performHow to perform

mid mid dilution HDFdilution HDFwith standard dialyzers?with standard dialyzers?


49/53

POST DILUTIONPOST DILUTION

PRE DILUTIONPRE DILUTION

PRE DILUTIONPRE DILUTION

high levels of ultrafiltration / reinfusionhigh levels of ultrafiltration / reinfusion

excellent removal of small molecular weight toxinesexcellent removal of small molecular weight toxines

excellent removal of high molecular weight toxinesexcellent removal of high molecular weight toxines

MD is the HDF on line offeringMD is the HDF on line offering

the higher depurationthe higher depuration

HFR Wh t i d b d?


50/53

HFR What is adsorbed?

Macrophage inflammatory protein- (MIP- )Macrophage inflammatory protein- (MIP- ) Tumor necrosis factor- (TNF- ) Monocyte chemotactic protein(MCP-1) Epithelial neutrophil activating

peptide 78 (ENA-78) Angiogenina

2 microglobulina Omocisteina

Interleukin 5 Interleukin 6


Interleukin 10 (?) Interleukin 12p70


Midle Molecule

HFR: clinical prescription


51/53

MIA Syndrome

HFR: clinical prescription

MalnutritionQuf

QR

QR = Quf

Selecta

Qb

Chronic infiammation

Atherosclerosis20

22

24

26

28

30

32

34

HD2sett

HD4sett

HD6sett

HD8sett

HD10sett

HFRstart

HFR2sett

HFR4sett

HFR6sett

HFR8sett

HFR10sett

HFR12sett

HFR16sett

HFR20sett

HFR24sett

2microglob

ulina(mg/L)

2.5

2

1.5

1

PCR

(mg/dL)

HD HFR

General poor condition

Old patientsDialytic ageComorbidity

HFR - SLEDHFR - SLED


52/53

HFR SLEDHFR SLED

SEMOGA BERMANFAATSEMOGA BERMANFAAT


53/53

HATUR NUHUNHATUR NUHUN

SEMOGA BERMANFAATSEMOGA BERMANFAAT

crs harkit 2011 prsnt

Documents