Management of Combined CHF and C by fjhuangjun

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									Management of
 Combined
CHF and CRF
    Ri 王薏茜
   2003-06-23
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…
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 >50% of ESRD patient mortality
CRF ↔ CHF (3)
incidence                 CAD      LVH         CHF
General population        5-12     20          5
Dialysis                  40       75          40
Renal transplant          15       50          -
CRF                       -        25-50       -


No/1000pts/year      20-44       45-64     >65
CV death             43          76        179
After transplant     3.1         7.7       -
Risk factors for CV diseases
   Normal population            Related to uremia               Related to dialysis
       Old age, male, race          Hyper/hypo tension              Hyper/hypo tension
       Hyperlipidemia               Anemia
       Hypertension, DM             Low HDL, High LDL               Malnutrition
       homocysteinemia              Hypertriglyceridemia            Hypoalbuminemia
       Physical inactivity          Lp(a)                           Low body mass index
       Family history               Hyperparathyoidism              Na water retention
       Menopause                    Ca X P
       Socioeconomic                Uremic toxins
        status                       Oxidative stress
       Smoking                      Impaired gibrinosysis
       Infectous agents             Insulin resistance
                                     Hymocysteine
                                     Thrombogenic factors
                                     Endothelialdysfunction
                                     Chronic inflammation
                                     Carbonyl stress
                                     Sleep apnea
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
HTN in ESRD: mechanism
   Total sodium increase
   Plasma renin activity increase
   Noradrenergic hyperactivity
   Na/water retention
   AV fistula
   Anemia
Hypotention in ESRD?
   BP<110: 4x increase in mortality
       Now suggested as a marker of ventricular
        systolic/diastolic dysfunction
IHD in ESRD
   At starting dialysis: 18-20% with IHD
       Presentation
            Infarction: 56%
            Angina:82%
            CABG: 14%
            Angioplasyt: 1%

                                    With IHD   Without IHD
     Progression to heart failure   24m        55m
     Mean survival time             44m        56m
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)
LVH in ESRD
   Mechanism
       Re-expression of fetel Growth Factor/GFR
       Myocyte death, fibroblast growth (ESRD>DM, HTN)
            Interstitial fibrosis
            Diastolic dysfunction
            Intolerate to volume change (wall stiffness)
            Early reflection
       arrhythmia
   Independent prognostic factor for survival !!
       LVMI> 125 mg/m2: 25% (4-y)
       LVMI< 125 mg/m2: 55%
       LVEF<40%: odds ratio for mortality: 1.89
Survival in ESRD with/without LVH
LVH in ESRD : prevalence
   In early renal dz (CCr>30ml/min)
       65% eccentric hypertrophy
       16% concentric hypertrophy
   In patients with CCr=10-30ml/min
       26% concentric hypertrophy
   In dialysis pts (CCr<10ml/min)
       44% eccentric
       42-50% concentric
LVH in ESRD:
independent factors for LVH
   Hypertention
       BP ↑ 5mmHg: LVMI ↑10g/m2
   Male gender
   BMI >25
   Hb <10-12
       Hb ↓ 0.5 mg/dl: LVMI ↑10g/m2
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
LVH in ESRD: role of anemia
   When Hb<10-12
       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?
CHF in ESRD
   Epidemiology
       In starting dialysis
             31% with CHF
             25% develop CHF later
       Mortality
             8.9% die of CHF/year
       Survival
                               With CHF              Without CHF
        4-y survival           20%                   60%
        Mean suvival           36 months (29m/45m)   62 months
Survival in ESRD with/without CHF
CHF in ESRD: factors
   Factors related to onset:
       Age
       DM
       Ischemic heart disease
   Factors related to recurrence:
       Ischemic heart disease
       Anemia
       Hypoalbuminemia
       hypertension
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
Management principles

   Preventive intervention should be
    initiated early in the first year of dialysis.
   Later treatment (CHF) has limited
    possibility of success.
Management principles
   Major goal: treating underlying factors
    predispose to heart failure
       HTN, DM, hyperPTH, dyslipidemia, anemia
       Treatment of hemodynamic overload
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
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
Management:
aggressive correction of anemia
   50% of CHF patients have Hb<12
   66-80% of class IV CHF pts have Hb<12
   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 Hb<12.5
            Keep serum ferritin>500ug/L, Sat>40%
Management:
aggressive correction of anemia

                          1-year Mortality in:

                             Class 3-4 CHF
                              patients: 30-50%
                             This trial: 7.1%
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.
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
Management:
intensive volume control
           sPB dBP BW CTI LA           EDD ESD LVMI %           Htc
                                                          LVH

Pre-HD     168   97   63.3 48    -     -     -      -     -     29.5
Post-HD 127      78   60.3 46    24.3 29.3   18.8   164   63    33.7
(3ms)
6ms        120   75   62.4 44    22.6 26.7   17.3   121   32    34.2
12ms       118   73   65.4 43    22.6 26.4   18.0   112   18    33.2

          Avoid rapid volume shift
          Maintaining a low dry weight
          Regression of LVH, LVD, LV stiffness
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!
Reference
   Seminars in dialysis 2003 vol 16(2):85-94
   J of Nephrology 2002 15:655-60
   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
Thank you for your
    attention !

								
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