Cardiorenal syndrome
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Transcript of Cardiorenal syndrome
Dr.Nagula Praveen
CARDIORENAL SYNDROMEDr.Praveen Nagula
Sir Arthur Guyton
Case scenario 71 yr old man complaints of severe SOB and chest pain. Past h/o HTN,CHF--NYHA IV,CKD. Temporary dialysis 3-4 times /week for acute on chronic
CKD. b/l crackles,pedal edema. CXR cardiomegaly,small rt pleural effusion,pulmonary
venous congestion. Echo –LVH,DD,EF 40%,PASP 45 mmHg. BUN -22 mmol/l s. creatinine was2.23 mg/dl CHF exacerbation–furosemide. Acute on chronic renal failure serum creatinine raised to
4.7 mg/dl –hemodialysis. Pericardial effusion and respiratory failure. Rx with
milirinone,dopamine,dobutamine,furosemide,thoracocentesis,perciardiocentesis –patient improved.
CARDIORENAL SYNDROME
TYPE 2
Introduction Definition Epidemiology Classification Pathophysiology Severe cardiorenal syndrome Diagnosis Treatment Prognosis Future Trials Take home message
Introduction
CRS increasingly has been used without a consistent or well accepted defintion.
Biomarkers can contribute to early diagnosis. CRS is defined as a condition characterised by
the initiation and progression of renal insufficiency sec to heart failure , term is also used to describe the negative effects of reduced renal function on heart and circulation.
Cluster of conditions complexity ---lack of clarity of with regard to diagnosis and management.
Definition
CRS can be generally defined as a patho physiologic disorder of the heart and kidneys whereby acute or chronic dysfunction of one organ may induce acute or chronic dysfunction of the other.
- JACC;vol 52:no 19 ,2008
SEVERE CARDIORENAL SYNDROME : A pathophysiologic condition in which combined cardiac
and renal dysfunction amplifies progression of the failure of the individual organ , so that CV morbidity and mortality in this patient group is at least an order of magnitude higher than in the general population
-Eur Heart Journal :vol 26 :2008
Simplistic view of CRS relatively normal kidney is dysfunctional because of a diseased heart , with the assumption that in the presence of a healthy heart the same kidney would perform normally.
Mechanisms in CRS
RAAS Increased SNA Reactive oxygen species Inflammation Endothelin effect Argininevasopressin effects BNP effects
EPIDEMIOLOGY
Age adjusted CVD mortality is about 30 times higher in CKD than in general population.
Risk of dying because of cardiovascular causes in patients with ESRD – 65 times higher in pts with 45-54 yrs, 500 times higher than general population in young cohort.
1/3 of patients with mild renal impairment –h/o overt CVD.
Pretransplant CVD risk marker of post transplant CVD –loss of grafts.
CLASSIFICATION
World congress of nephrology Based on patho physiology 5 sub types 1.CRS type 1 : acute cardio-renal syndrome 2.CRS type 2 : chronic cardio-renal syndrome 3.CRS type 3 : acute reno-cardiac syndrome 4.CRS type 4 : chronic reno-cardiac syndrome 5.CRS type 5 : seconary cardio-renal syndrome
Guyton model
Extensively described normal physiological interactions between the control of extracellular fluid volume by the kidney and the systemic circulation by the heart.
Figure 1 Pathophysiological basis of the severe cardiorenal syndrome.
Bongartz L G et al. Eur Heart J 2005;26:11-17
European Heart Journal vol. 26 no. 1 © The European Society of Cardiology 2004; all rights reserved.
Cardiorenal connection
When one of the organs fails , a vicious cycle develops in which the renin angiotensin system ,the NO-ROS balance,SNS ,inflammation interact and synergize ,here called the cardiorenal connection
Important molecules
NGAL—neutophilgelatinase assosciated lipocalin.
Cystatin C Kidney injury molecule 1 N acetyl β (D) glucosaminidase Netrin 1 NHE –sodium hydrogen exchanger GST –glutathione s transferase L FABP –l type fatty acid binding protein. IL-6,8,18
Anemia –a crucial factor in the vicious cycle of CRS
Integral part of advanced renal failure. Independent effect on CVD in CKD Every 1 gm/dl drop in mean hemoglobin –risk of
cardiac failure increases by 25%. Increases LVH by 42%,increases death risk by 14%. Erythropoietin levels barely go up –TNF,IL -6 . TNF – interferes with absorption of iron from gut. Proteinuria –loss of EPO ,Iron ,transferrin---anemia . Glycosylation of interstitial cells –EPO in diabetics.
Blood pressure
Blunting of nocturnal BP in uremics It is due to LVH or it leads to LVH High risk of vascular diseases in CKD. Decreased cardiac perfusion due to LVH –
ischemia. At any given SBP –pulse pressure > 50 mm hg
correlates with increased risk of death.
Calcium phosphate product
Prog nephron loss- - phosphate retention , hypocalcemia- sec hyperparathyroidism.
It is independent risk factor of CVD. >60 mg2/m2 ---metastatic calcification. Vascular calcification begins 10-20 yrs earlier in
these patients. Calcium regulatory proteins deficiency -- x2
hereman schmid glycoprotein,matrix G1 a protein –extraosseus calcification.
Proteinuria,hypoalbuminemia
Hypoalbuminemia Hyperlipidemia Coagulation abnormalities following
hyperfibrinogenemia , increase in factor III,vWBF. Microalbuminuria—marker of vascular endothelial
dysfunction. Hypoalbuminemia—risk factor in HD pts. Hyperhomocysteinemia , impaired NO synthesis. Increased plasma volume in HD pts. Albumin-- Negative acute phase protein. Increased acute phase proteins in HD pts.
MIA
Malnutrition – inflammation – atherosclerosis syndrome. IL1 IL6 TNF increased 8-10 times in ESRD IL – 6 pro atherogenic cytokine. Reduced clearance of cytokines , accumulation of AGE,
unrecognised persistent infections , graft and fistula infections.
• IL-6 stimulate adhesion molecules VCAM,ICAM—attachment of leukocytes—endothelial dysfunction.
• Down regulates albumin mRNA.• Inhibits albumin synthesis , inhibits appetite directly ,
indirectly through leptin.• Sustained inflammatory response—ED-oxidative stress,
complement activation—increased CV mortality.
Role of ADMA
Asymmetric dimethyl arginine New emerging CV risk factor in uremic
patients. Competitive NO synthase inhibitor. Decreased NO availability. Degraded by dimethyl arginine dimethyl
hydrolase –renal tissue. ADMA accumulates with renal failure. Second strongest predictor of CV mortality after
Age. Reduced by ACEI ,ARBs,insulin sensitizers.
Angiotensin II
RAAS –diabetics and HTN Angiotensin II –vasoactive peptide,true cytokine
that regulates cell growth,inflammation and fibrosis.
Increases TNF alpha,IL-6,NF kB Stimulates superoxide lipid peroxidation and
inactivation of NO producing oxidative stress. Promotes atherosclerosis. Endothelial cell apoptosis MMP 1,MMP-9 lead to proliferation,migration of
smooth muscles cells—fibrosis.
Hyperhomocysteinemia
Strong predictor of CVD in general population. Moderate levels 16-30umol/l in CKD.(4.4-
10.8umol/L) Enhances vascular smooth muscle proliferation. Prothrombotic environment in coagulation. Activates factor V,X,XII. Decreased activation of protein C, thrombomodulin. Modualtion of annexin II. Oxidative stress --- ROS—binding to NO---
homocysteinated acylated proteins—acc of S.-adenosyl homocysteine –inhibitor of transmethylation reactions.
lipids
Reduced Apo A containing HDL. Increased Apo B VLDL,IDL.LDL. Preferential increase in IDL and small dense LDL. Decreased Apo A II /Apo C III ratio is
hallmark. HD attenuates the dyslipidemia,PD aggravates
it.
CRP
CRP –directly involved in atherothrombogenesis Induces expression of adhesion molecules E selectin,VCAM -1 ICAM 1 by endothelial cells.—
chemoattractant to monocytes,mediated by MCP 1.
Opsonises LDL Activates complement via classical pathway. Decreases NO synthesis. Progression of atherosclerosis. Stimulates tissue factor—thrombogenesis.
CRS type 1
Acute cardiac failure –worsening renal function. Mechanisms are: 1. acute hypoperfusion leading to decreased
GFR 2. decreased oxygen delivery. 3.resistance to ANP /BNP 4.cell necrosis/apoptosis
AKI severe in those with impaired LV EF than with preserved EF imparting the importance of perfusion of kidneys-- >70 %cardiogenic shock.
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Ronco, C. et al. J Am Coll Cardiol 2008;52:1527-1539
CRS Type 1
Early diagnosis of CRS type 1 is important as serum creatinine rises when the AKI is already established.
Novel biomarkers are needed –rise within few hours of onset of AKI
NGAL –neutrophil gelatinase assosiated lipocalin –earliest and sensitive marker of ischemic/nephrotoxic injury detected in blood /urine.
Kidney injury molecule 1 is a highly specific marker for ischemic AKI.
Biomarkers in the diagnosis of AKI
Biomarker Assosciated injury
Cystatin C Proximal tubule injury
KIM 1 Ischemia and nephrotoxins
NGAL Ischemia and nephrotoxins
NHE3 Ischemia,prerenal ,postrenal AKI
GST Proximal tubule injury ,acute rejection
GST Distal tubule injury,acute rejection
L-FABP Ischemia and nephrotoxins
Cyr 6 1 Ischemic ATN
NETRIN 1 Ischemia and nephrotoxins,sepsis
Management of CRS 1
Diuretics –useful in volume overloaded non hypotensive patients.
Loop diuretics ,thiazides Overzealous use –worsening renal function Exacerbates neuro hormonal activity , activates RAAS , Inc
SVR ,worsens LVF . Inotropes --dopamine,dobutamine,milirinone Vasodialtors – nesiritide Wang et al –no effect of nesirtide on GFR, RPF,urine
output ,sodium excretion Ultrafiltration(aquapheresis) Arginine vasopressin receptor antagonists—tolvaptan EVEREST trial Adenosine A1 receptor antagonists
CRS type 2
Chronic congestive cardiac failure –chronically reduced renal perfusion –chronic renal venous congestion—chronic renal dysfunction.
Prevalence of renal dysfunction in CHF is approx .25%
Pathophysiology is poorly understood. ESCAPE study –no relation between the
pulmonary artery catheter measured blood variables and serum creatinine.
Pathophysiology
Low cardiac output--- activation of RAAS –SNS ---subclinical inflammation ---endothelial dysfunction—increased renal vascular resistance—accelerated atherosclerosis.
Relative or absolute erythropoietin deficiency. Activation of the receptor of erythropoietin leads
to reduced risk of apoptosis , inflammation and fibrosis.
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Ronco, C. et al. J Am Coll Cardiol 2008;52:1527-1539
CRS Type 2
Management
Diuretics – volume expanded state ACEI ARBs block RAAS ---dec LVH,proteinuria,decrease
progression of CKD . Vasodilators may also be useful.
Cardiorenal syndrome type 3
AKI --- RAAS , NO reactive oxygen species , SNS.---acute cardiac dysfunction by fluid overload and accelerated HTN ---manifested as acute pulmonary edema.
Hyperkalemia---cardiac arryhthmias and SCD Metabolic acidosis –cardiac inotropy –pulmonary
vasoconstriction –RHF. Acute uremia --- myocardial contractility affected. Renal ischemia --- SIRS –proinflammatory
cytokines--- delayed cardiodepressant response. Cardiac troponins , NT pro BNP,TNF,IL—6, Myeloperoxidase ---early detection
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Ronco, C. et al. J Am Coll Cardiol 2008;52:1527-1539
CRS Type 3
Management
Rx of accelerated HTN ,hyperkalemia,metabolic acidosis.
Hemodialysis. CRRT
CRS 4
Primary CKD –CHF Microalbuminuria ---increases CV risk by 2-4 times. Declining GFR – assosciated with increasing CV risk. Anemia, hypervolemia , HTN, abn calcium and
phosphate metabolism,oxidative stress and inflammation,endothelial dysfunction,ADMA,hyperhomocystenemia,proteinuria
Hypervolemia and hypertension – lvh –IHD—DCM Abnormal calcium and phosphate metabolism ---
coronary artery calcification noted.
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Ronco, C. et al. J Am Coll Cardiol 2008;52:1527-1539
CRS Type 4
Oxidative stress and inflammation : enzymes involved are NADPH oxidase,SOD,NOS,myeloperoxidase are capable of oxdizing LDL.
Increased levels of inflammatory biomarkers like CRP,IL-6,fibrinogen –along with oxidized LDL – proatherogenic – endothelial dysfunction.
Worsened by co existing hypoalbuminemia.---scavenger
Increased production of AGE ---pentosidine N carbo methyl lysine --accelerated atherosclerosis.
Endothelial dysfunction – ADMA ADMA –competitive inhibitor of NO synthase.renal
tissue.
Management
Cessation of smoking,control of diabetes,HTN. Correction of anemia –iron supplements and
erythropoietin Hb 11-12 gm % hct >36% Loop diuretics ,ACEI, ARB s,bb Calcium * phosphate ionic product to be kept
below 50 mg2/m2 Sevelamer –better one in retarding calcification. Statins --anti proteinuric effect Vitamin E N acetyl cysteine.
CRS 5
Cardiac and renal dysfunction due to acute or chronic systemic cause.
Sepsis acutely. Diabetes,amylodiosis,SLE TNF alpha , IL 1B, IL – 6. Pathophysiology of CRS type 1 and 3 – sepsis CRS type 2 and 4 –chronic
Copyright ©2008 American College of Cardiology Foundation. Restrictions may apply.
Ronco, C. et al. J Am Coll Cardiol 2008;52:1527-1539
CRS Type 5
Management
Treatment of underlying cause. Vasopressors Inotropes Diuretics Intensive renal replacement therapy in sepsis.
New drugs
Neutral endopeptidase NEP• An endothelial metalloproteinase– degradation of
several regulatory peptides including natriuretic peptides.
• Inhibition augments vasodilation and natriuresis. NEP/ACEI – vasopeptidase inhibitors –
omapatrilet.• Decreases protetinuria by 20 % in CKD.• Major disadvantage is angioedema. Adenosine A1receptor antagonist BG 9719. Targeted renal delivery of drugs—
fenoldopam ,nesiritide.
Trials
EVEREST trial ESCAPE study HOPE,HDFP,MRFIT,HOT ,framingham heart
study--- increased cardiovascular risk begins early in renal insufficiency.
SHARP trial—lowering of LDL by 1 mmol/l for for 4-5 yrs reduces risk of coronary event by 20%.
EUPHORIA trial UNLOAD trial
Future
early diagnosis of the syndrome is needed.
Pathophysiology of the syndrome to be known in detail.
New alternative therapies other than diuretics are expected with results from large trials.
The transplantation of organs to be encouraged.
Diagnostic criteria to be developed.
Take home message
CRS is a pathophysiological condition. Treatment is to be individualized based
on the etiology. Early diagnosis is important for better
survival. Early novel biomarkers are to be used in
diagnosis. Each patient with either CKD,CVD to be
assessed with risk factors and followed up.
Scope for research.
References
Postgraduate medicine (recent advances in medicine)XXI
Medicine update ,volume 20,2010. Oxford journals – guyton revisited SCRS JACC – vol 52,no.19 2008---cardiorenal
syndrome. Medscape education. Experimental and clinical cardiology—pubmed. Circulation 2004 journal 1514-1517.
Thank you
Sagittarian