1 Managing Chronic Heart Failure Patient in Chronic Kidney Disease BS TRẦN HỮU HIỀN ĐHYK PHẠM NGỌC THẠCH INTRODUCTION  Epidemiology  Pathophysiology  Management  Modification of risk factors  Diuretic  Angiotensin-converting enzyme inhibitors  Angiotensin II receptor blockers  Beta-blockers  Digoxin  Oxidative stress and hemodialysis patients EPIDEMIOLOGY U.S Renal Data System USRDS 2012 Annual Data Report: Atlas of ChronicKidney Disease and End-Stage Renal Disease in the United States Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 2012 PATHOPHYSIOLOGY CARDIO-RENAL SYNDROMES (CRS) GENERAL DEFINITION Disorders of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other ACUTE CARDIO-RENAL SYNDROME (TYPE 1) Acute worsening of cardiac function leading to renal dysfunction CHRONIC CARDIO-RENAL SYNDROME (TYPE 2) Chronic abnormalities in cardiac function leading to renal dysfunction ACUTE RENO-CARDIAC SYNDROME (TYPE 3) Acute worsening of renal function causing cardiac dysfunction CHRONIC RENO-CARDIAC SYNDROME (TYPE 4) Chronic abnormalities in renal function leading to cardiac disease SECONDARY CARDIO-RENAL SYNDROMES (TYPE 5) Systemic conditions causing simultaneous dysfunction of the heart and kidney House AA, Anand I, Bellomo R, Cruz D, Bobek I, Anker SD, Acute Dialysis Quality Initiative Consensus Group Defiition and classifiation of cardio-renal syndromes: workgroup statements from the 7th ADQI consensus conference Nephrol Dial Transplant 2010;25(5):1416–20 MANEGEMENT Modification of risk * factors Smoking cessation Exercise Weight reduction to optimal targets Lipid modification recognizing Optimal diabetes control HbA1C 5.5 mEq/L should prompt a reduction in the ACE inhibitor dose *N Engl J Med 2004 Aug 5;351(6):585-92 17 Angiotensin II receptor blockers  Alternative in patients intolerant of ACE inhibitors due to cough,  Combination with ACE inhibitors in patients who remain severely symptomatic on conventional therapy Am Heart J 2007 Jun;153(6):1064-73 18 Beta-blockers 19  Recommended for all patients with stable mild, moderate or severe HF who are on standard treatment including diuretics and ACE inhibitors*  In the SOLVD study, treatment with beta-blockers was associated with a 30% decrease in the risk of worsening renal function, both in the ACE inhibitor and the placebo groups (RR 0.70, 95% CI 0.570.85)** *J Am Coll Cardiol 2004;44:1587-1592 **Am Heart J 1999 Nov;138(5 Pt 1):849-55 Digoxin 20  Not affect survival but led to a 28% reduction in HF hospitalizations  Used safely in patients with HF and renal insufficiency,  Initiated without a loading dose and maintained at a low dose (0.125 mg), alternating days  Serum digoxin levels should be monitored to maintain a serum concentration in the acceptable range of 0.5-1.0 ng/mL  Monitor carefully for symptoms and signs of digoxin toxicity N Engl J Med 1997 Feb 20;336(8):525-33 Oxidative stress and hemodialysis patients 21  Supplementation with 800 IU/day vitamin E reduces composite cardiovascular disease endpoints and myocardial infarction*  Treatment with acetylcysteine (600 mg BID) reduces composite cardiovascular end points** *Lancet 2000;356:1213-1218 **Circulation 2003 Feb 25;107(7):992-5 HOME MESSAGE  Modification of risk factors  ACE inhibitors, ARBs, and β-blockers are the fist-line drugs treat HF in CKD  Loop diuretics are the first line treat fluid overload  Digoxin use low dose (0.125mg) and close monitoring  Oxidative stress and hemodialysis patients: vitamin E and acetylcysteine 22 23 THANKS FOR LISTENING ... reducing disease progression in both the heart and the kidney Arch Intern Med 2000 Mar 13;160(5):685-93 14 Angiotensin-converting enzyme inhibitors  In patients with moderate or severe renal insufficiency,... Angiotensin-converting enzyme inhibitors  When the initiation of ACE inhibitor therapy leads to an increase in serum creatinine levels >30% above baseline  ACE inhibitors should be discontinued,... to individualized targets * KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease Diuretics Major clinical role in reducing fluid overload in patients