U of U PA School Cardio-Renal Syndrome

Why do patients with CKD rarely make it to ESRD?

CKD causes cardiac death

-Most common cause of death in CKD

How is CKD and CVD intertwined? (5)

Hypertension and DM cause majority of kidney failure

HF associated with CKD

CKD is pro-inflammatory and causes peripheral arterial disease and vascular calcification

-Leads to ischemic heart disease and ACS

CKD causes anemia and electrolyte disturbances worsening HF progression

CKD increases arrhythmia potential

What are the tyeps of cardio-renal syndrome (CRS)?

Type 1 - acute cardiorenal

Type 2 - chronic cardiorenal

Type 3 - acute nephrocardiac

Type 4 - Chronic nephrocardiac

Type 5 - systemic disease

What is type 1 CRS?

Abrupt worsening of cardiac function leads to AKI

What is type 2 CRS?

Chronic cardiac dysfunction causing progressive and permanent CKD

What is type 3 CRS?

Prompt decrease in renal funtion contributing to acute cardiac disorders

What is type 4 CRS?

CKD inducing declining cardiac function, hypertrophy, and/or adverse cardiac events

What is type 5 CRS?

Systemic condition resulting in cardiac and renal dysfunction

What often causes type 1 CRS? (4)

ACS

Valvular disease

Pulmonary embolism

Complication of cardiac surgery - significant period of hypotension causing insult

What is the mechanism of type 1 CRS?

Decreased cardiac function leads to decreased renal blood flow and EABV

Increased venous congestion limiting renal kidney perfusion

What increases the risk of type 1 CRS?

Underlying CKD

How is type 1 CRS diagnosed?

Oliguria best predictor

Serum creatinine

Echo can evaluate cardiac function

How can type 1 CRS be prevented/treated? (4)

Treat venous congestion with lasix but avoid further perfusion insults

Avoid volume depletion

Avoid nephrotoxic meds

Support heart

How should meds be managed in type 1 CRS?

Hold metformin and ACE

Renally dose meds

How should the heart be supported in type 1 CRS?

Inotropes

Mechanical circulatory support devices

Prevent further insults

What CRS is hard to distinguish from CRS 2?

CRS 4

Can have had CRS 1 inciting event that never fully recovered

What is the mechanism of CRS 2?

Chronic hypoperfusion and renal vein congestion from LV dysfunction causes

-renal fibrosis

-decrease in GFR

Increased atherosclerosis from hypertension can cause renal artery stenosis

How is CRS 2 diagnosed?

Echo for LV function and valve function

GFR and uACR - kidney function heart map

BNP

How is CRS 2 treated?

GDMT for HF

Optimize hypertension and DM control

Limit nephrotoxic meds

What is the mechanism of CRS 3? (5)

AKI precluding cardiac event

Hyperkalemia -> ventricular tachycardia

Hypocalcemia -> arrhythmias

Volume overload due to oliguria or inflammation -> RAAS -> cardiac distention causing dysfunction and pulmonary edema

Metabolic acidosis -> RV failure and pulmonary vasoconstriction

What is the mechanism of CRS 3 in pediatrics?

Glomerulonephritis/post streptococcal glomerulonephritis -> oliguria -> volume overload -> cardiac dysfunction

How can CRS 3 be diagnosed? (5)

BMP

Echo

ABG

BNP (if fluid overload suspected)

Renal ultrasound

-Rules out CKD - US will show renal atrophy in CKD

What is the treatment for CRS 3?

Reverse causes

Diuretics

Volume/sodium restriction

What is the mechanism for CRS 4?

Calcium/phosphorus abnormalities -> valve stenosis and vascular calcification

CKD causing elevated uremia and volume/electrolyte disturbances can cause SCD

Anemia worsens cardiac perfusion and contractility

How is CRS 4 diagnosed? (5)

BNP

GFR

Echo

Lipid screening

PREVENT calculator

How is CRS 4 treated? (4)

Optimize DM and hypertension control

Monitor and prevent hyperkalemia

Management of calcium and phosphorus levels

Anemia treatment

How should DM and hypertension control be optimized in CRS 4?

ACE/ARB/ARNI

Spironolactone for HF

BGL control

What can cause CRS 5? (4)

Sepsis - increased troponin without ACS, increased mortality

Burns

Significant trauma

Amylodosis

How is anemia treated in CRS 4?

Iron supplements

EPO stimulating agents

What is the mechanisms for CRS 5?

Hypotension from endothelin dysfunction

Iatrogenic volume overload

How is CRS 5 treated?

Treat underlying cause

Pressors

Volume restriction

What is hepatorenal syndrome?

End-stage cirrhosis causes a rapid onset of irreversible renal failure without evidence for an alternative diagnosis.

What are the types of hepatorenal syndrome?

Type 1 - Acute - 100% mortality in 2 months

Type 2 - Chronic - median survival 6 months

How is hepatorenal syndrome diagnosed?

Diagnosis of exclusion

Rule out

-Sepsis with blood cultures

-Pre renal failure - d/c diuretics and administer NS and IV albumin

-Nephrotic syndrome or parenchymal kidney disease

How does hepatorenal syndrome develop? (5)

Cirrosis + portal hypertension ->

Increased splanchnic vasodilation and arterial underfilling ->

Renal vasoconstriction due to RAAS and endothelin ->

Increased vasoconstriction, decreased renal vasodilation ->

Hepatorenal syndrome

What exam findings are consistent with hepatorenal syndrome? (5)

Ascites

Jaundice

Hepatomegaly

Encephalopathy - ammonia

Coagulopathy

What is the definitive treatment for hepatorenal syndrome? What procedures can act as a bridge to this?

Liver transplant is definitive treatment

Treatment to bridge to transplant

-TIPS - transjugular intrahepatic portosystemic shunt

-Dialysis

What can be used as supportive care for hepatorenal syndrome?

d/c all antihypertensives

IV albumin

Vasoconstrictors

Where should hepatorenal syndrome be managed?

Type 1 - ICU management

Type 2 - if stable treat from home