Management of Combined CHF and CRF

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Management of Combined CHF and CRF

• Ri ???
• 2003-06-23

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CRF ? CHF (1)

• Average SCr of CHF patient 1.5 mg/dl
• Mortality of CHF patients
• 40 sudden death
• 40 worsening CHF
• 20 others
• Cancer, COPD, infection

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CRF ? CHF (2)

• CV disease in CRF patients
• At starting diaslysis
• 30-70 HTN
• 60 IHD
• 18-20 LVH
• 31-34 CHF
• CVD mortality 5-50x(10-30x) more than in normal
  population
• Account for gt50 of ESRD patient mortality

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CRF ? CHF (3)
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Risk factors for CV diseases

• Normal population
• Old age, male, race
• Hyperlipidemia
• Hypertension, DM
• homocysteinemia
• Physical inactivity
• Family history
• Menopause
• Socioeconomic status
• Smoking
• Infectous agents

• Related to uremia
• Hyper/hypo tension
• Anemia
• Low HDL, High LDL
• Hypertriglyceridemia
• Lp(a)
• Hyperparathyoidism
• Ca X P
• Uremic toxins
• Oxidative stress
• Impaired gibrinosysis
• Insulin resistance
• Hymocysteine
• Thrombogenic factors
• Endothelialdysfunction
• Chronic inflammation
• Carbonyl stress
• Sleep apnea

• Related to dialysis
• Hyper/hypo tension
• Malnutrition
• Hypoalbuminemia
• Low body mass index
• Na water retention

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HTN in ESRD

• Strongest risk factor of LV hypertrophy
• For SCr 3.3 1.1 mg/dl
• Optimal BP 3
• High normal 9
• Stage 1 HTN (140-160) 34.4
• Stage 2/3 HTN (160-200) 52.5
• Mortality vs hypertension J-shaped

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HTN in ESRD mechanism

• Total sodium increase
• Plasma renin activity increase
• Noradrenergic hyperactivity
• Na/water retention
• AV fistula
• Anemia

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Hypotention in ESRD?

• BPlt110 4x increase in mortality
• Now suggested as a marker of ventricular
  systolic/diastolic dysfunction

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IHD in ESRD

• At starting dialysis 18-20 with IHD
• Presentation
• Infarction 56
• Angina82
• CABG 14
• Angioplasyt 1

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IHD in ESRD risk factors

• Older age
• DM
• HTN
• Dyslipidemia
• Hypoalbuminemia
• Hyperhomocysteinemia
• 83 of patients having levels higher than 90th
  percentile
• Associate with 7x increase in mortality
• Lp(a)

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LVH in ESRD

• Mechanism
• Re-expression of fetel Growth Factor/GFR
• Myocyte death, fibroblast growth (ESRDgtDM, HTN)
• Interstitial fibrosis
• Diastolic dysfunction
• Intolerate to volume change (wall stiffness)
• Early reflection
• arrhythmia
• Independent prognostic factor for survival !!
• LVMIgt 125 mg/m2 25 (4-y)
• LVMIlt 125 mg/m2 55
• LVEFlt40 odds ratio for mortality 1.89

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Survival in ESRD with/without LVH
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LVH in ESRD prevalence

• In early renal dz (CCrgt30ml/min)
• 65 eccentric hypertrophy
• 16 concentric hypertrophy
• In patients with CCr10-30ml/min
• 26 concentric hypertrophy
• In dialysis pts (CCrlt10ml/min)
• 44 eccentric
• 42-50 concentric

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LVH in ESRD independent factors for LVH

• Hypertention
• BP ? 5mmHg LVMI ?10g/m2
• Male gender
• BMI gt25
• Hb lt10-12
• Hb ? 0.5 mg/dl LVMI ?10g/m2

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LVH in ESRD hemodynamic mechanism

• Volume overload
• AV fistula
• Na/water retention
• Anemia
• Pressure overload
• Aotic wall/ventricular wall stiffness
• Atherosclerosis
• RAS overactivity ACEI
• Dialysis ? Ca(inotropic) and sympathetic tone

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LVH in ESRD role of anemia

• When Hblt10-12
• Reactive hemodynamic change
• Stroke volume ?
• Heart rate ?
• Odds ratio for CRF 1.32 / 0.5 Hb ?
• Odds ratio for ESRD 1.46 / 1 Hb ?
• EPO?

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CHF in ESRD

• Epidemiology
• In starting dialysis
• 31 with CHF
• 25 develop CHF later
• Mortality
• 8.9 die of CHF/year
• Survival

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Survival in ESRD with/without CHF
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CHF in ESRD factors

• Factors related to onset
• Age
• DM
• Ischemic heart disease
• Factors related to recurrence
• Ischemic heart disease
• Anemia
• Hypoalbuminemia
• hypertension

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D/D intrinsic myocardial dysfunction v.s. pure
volume overload

• Echocardiography
• Radionuclide tecniques
• ANF and BNF(brain natriuretic factor)
• Stress receptor in atrium?release of ANF, BNF
• Stress receptor in ventricle?release of BNF
• NF receptors in kidney, adrenal glomerulose,
  vascular smooth muscle
• Na excretion, vasodilatation, renin/aldosterone
  ?,
• ANF associated more with volume overload
• BNF associated more with ventricular dysfunction

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Management principles

• Preventive intervention should be initiated early
  in the first year of dialysis.
• Later treatment (CHF) has limited possibility of
  success.

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Management principles

• Major goal treating underlying factors
  predispose to heart failure
• HTN, DM, hyperPTH, dyslipidemia, anemia
• Treatment of hemodynamic overload

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Pharmacologic therapy

• Diuretics
• Higher dose/ combine thiazide/ IF continuous use
• Monitor K, regular supplement
• ACEI/Angiotensin Receptor Blockers
• proven survival benefit, IHD?,LVMI?, GFR decline?
• If hyperkalemia/renal function? hydralizine
  nitrate
• Side effect anemia EPO ?, bone marrow
  ultilization of EPO?
• Beta-blocker IHD, HTN, CHF
• Digoxin
• Cleared by kidney, NOT removed by dialysis
• Impact on symptom, functional capacity,
  hospitalized frequency, NOT on survival

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Management aggressive correction of anemia

• CRA syndrome cardio-renal-anemia
• Anemia ? CHF
• Damaged myocyte
• EPO production?
• Depress progenitor erythrocyte in bone marrow
• Interfere with RE system release of iron

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Management aggressive correction of anemia

• 50 of CHF patients have Hblt12
• 66-80 of class IV CHF pts have Hblt12
• Clinical trial in 2001
• 126 pts anemic, CHF treatmtne-resistant, NYHA
  class 3-4
• Target goal keep Hb 12.5-13 for 12.4 8.2 m
• Mean
• EPO 4000-5000 u if Hblt12.5
• Keep serum ferritingt500ug/L, Satgt40

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Management aggressive correction of anemia

• 1-year Mortality in
• Class 3-4 CHF patients 30-50
• This trial 7.1

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Management intensive volume control

• Basis
• LVH accounts for large No of mortality in ESRD
• sBP elevation is the strongest risk factor for
  LVH
• Regression of LVH with BP control is well
  established
• Difficulty in controlling BP in ESRD pts, may be
  due to hidden volume expansion, which is out of
  reach of antihypertensive medications.

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Management intensive volume control

• Effect of intensive hemodialysis on BP control
• Mean
• 12h H/D per week, without antihypertensive drug
• As much UF as possible, without excess BP drop
• Dietary salt restriction
• 3 months of intensive volume control
• 12 months of follow up

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Management intensive volume control

• Avoid rapid volume shift
• Maintaining a low dry weight
• Regression of LVH, LVD, LV stiffness

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Conclusion

• CRF patients have a very high risk of develop
  CVD
• HTN, LVH, IHD, CHF
• Account for more than 50 of ESRD patient
  mortality
• Management
• risk reduction anemia, BP control,
• volume management,
• medication toward symptoms diuretics, digoxin,
  ACEI/ARBs, beta-blockers, correct dyslipidemia
• Proper dialysis
• Early intervention!

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Reference

• Seminars in dialysis 2003 vol 16(2)85-94
• J of Nephrology 2002 15655-60
• Clinical nephrology 2002 vol 58 (supple1)s37-45
• Ame J of Kidney diseases 2001 vol 38(4,
  supple1)s38-46
• Peritoneal dialysis international. 2001 Vol
  21(S3)s236-9
• Seminars in nephrology. 2001 vol 21 (1)3-12

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Thank you for your attention !