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Heart and Kidney, for better or for worse
P. van Paassen, MD, PhDDept. Nephrology and Clinical ImmunologyMaastricht UMC+
Hartfalen dag Zeist, 29 09 17
Geen (potentiële) belangenverstrengeling
Voor bijeenkomst mogelijk relevante relaties:
Bedrijfsnamen
• Sponsoring of onderzoeksgeld
• geen
• Honorarium of andere (financiële) vergoeding
• geen
• Aandeelhouder • geen
• Andere relatie, namelijk … • geen
Disclosure potential conflicts of interest
Ronco et al. J Am Coll Cardiol 2008
a double edged sword
Naranjo et al. Dis Mon 2017
GFR measurements
renal function
endogenous, creatinine
creatinine clearance
[CrCl]
MDRD
CKD–EPI
exo–
Inulin/DTPA/iothalamate
𝐶𝑟𝐶𝑙 =𝑈𝐶𝑟 × 𝑉
𝑃𝐶𝑟
U-protS-albumin/urea/Na/KCa/P/PTHTot CO2Hemoglobin/EPO
over– and underestimation of renal function
Webster et al. Lancet 2017
*Cystatin C may be a better marker of renalfunction
“normal” decline in eGFR
CKD N eGFRt=0 follow–up, yr. decline/yr.
Levey et al.J Am Soc Nephrol, 1991 1, 2, 3 28 37.1 [8.7] 1.2 –3.7 [7.6]
4, 5 63 15.0 [4.5] –4.3 [4.7]
Eriksen et al.Kidney Int, 2006 3 3047 55.1 [50.8 – 57.9] 3.7 –1.03
Levin et al.Am J Kidney Dis, 2008 3, 4, 5 4231 33.0 2.6 –2.65
*rapid decline per year if eGFR ≥5 mL/min/1.73m2
CKD and cardiovascular disease [1]
Go et al. N Engl J Med 2004
coronary artery calcification among patients with CKD
Chen et al. JAMA Cardiol 2017
risk of CVD depends on calcification among patients with CKDadjusted for CKD, HbA1c, P, FGF23, etc.
Chen et al. JAMA Cardiol 2017
pathophysiology of the cardiorenal syndrome type 2
heart failure induced kidney damage
the “normal” cardiorenal axis
low cardiac output [CO]genetics
environment
“compensated” kidney
modified from Ronco et al. J Am Coll Cardiol 2008
Kidney “compensation”HF: a syndrome of renal sodium and
water retention
Cardio-renal interactions in volume expansion and congestion in chronic heart failure.
Wayne L. Miller Circ Heart Fail. 2016;9:e002922
Paradigm of interstitial and intravascular volume expansion in chronic heart failure.
Wayne L. Miller Circ Heart Fail. 2016;9:e002922
stable glomerular filtration rate [GFR]
normal GFR during the first weeks,[1]
LAD coronary artery ligation reserve capacity; male[2]
[1]Lekawanvijit et al. Am J Physiol Heart Circ Physiol 2012[2]Levey et al. Ann Int Med 1999
renal autoregulation; constant over MAP 80–170 mmHgvascular smooth muscle cells and tubuloglomerular feedback
blood flow
capillary pressure
arteriolar resistance
Pollak et al. Clin J Am Soc Nephrol 2014
Structure of the renal corpuscle, looking into the Bowman’s capsule at glomerular capillary
tuft.
Martin R. Pollak et al. CJASN 2014;9:1461-1469
©2014 by American Society of Nephrology
2.10*6 nephrons
major determinants of [glomerular] ultrafiltration
Kf, ultrafiltration coefficient
πA, oncotic pressure
P, hydraulic pressure
QA, plasmaflow
Pollak et al. Clin J Am Soc Nephrol 2014SNGFR, single–nephron GFR
low CO
RAS, SNS
IVP
NPs
water
solutes
macula densa
NaCL content determinessecretion of adenosine by MDas marker of GFR, leading tot constriction of v afferent=TGF
Peritubular capillariesCountercurrent Osmolar gradient medulla
RAS in response to decreased renal perfusion
ATII
SNS
intraglomerularpressure
increased GFR,
single nephronlow Na,
low Cl
renin
efferent arterioleRAS
FF=GFR/ERPF
water
solutes
expanding intravascular fluid due to sodium retention
65%
20%
10%
5%
ATII ALDO
↑ ↑
↑
Na, %
hyperfiltration; the other side of the medal?glomerular hyperfiltration and cardiovascular events in 8749 participants
Reboldi et al. Kidney Int 2017
95th percentile
5th percentile
HR 1.6 [95% CI, 1.1 – 2.3]
CVE defined asinfarction,
heart failure,
revascularisation,
sudden cardiac death
type 2, chronic cardiorenal syndrome
chronic hypoperfusionincreased renal vasc. resistance
renal congestion
anemia, hypoxiaRAS[!], SNS[!]
Na, water retentionCa, P
hypertension
sclerosis and fibrosis
modified from Ronco et al. J Am Coll Cardiol 2008
[acute] subtle renal inflammation after LAD coronary artery ligation; ischemia
Lekawanvijit et al. Am J Physiol Heart Circ Physiol 2012
KIM–1*
*kidney injury molecule–1
also, increased macrophage infiltration and IL–6 mRNA
interstitial fibrosis can be found after 4 – 16wks
Lekawanvijit et al. Am J Physiol Heart Circ Physiol 2012
picrosirius red
1wk
ATII causes epithelial mesenchymal differentiation/fibrosis
• ATII stimulates renal Smads phosphorylation and the TGFβ axis
Smad2
Carvajal et al. Kidney Int 2008
HK2
cobblestone spindle-shaped,
fibroblast like
IFTA is common among patients with end-stage HF
Golestaneh et al. J Heart Lung Transplant 2014
male/female 13/1
HF, ischemicHF, non-ischemicHF, amyloidosis
851
eGFR, mL/min 29–55
uProt, gm/d <0.5
IFTA<30%
30-60%>60%
741
PAS
but, it’s not only a “forward” problem –inverse association between eGFR and CVP >5 mmHg
adjusted forage,
sex,
cardiac index
Damman et al. J Am Coll Cardiol 2009
r = -0.212, P <0.0001
HF a state of renal sodium and volume retention
• Osmoregulation (Pna, AVP)
• Volumeregulation (ANGII/Aldo)
• However far more complicated in HF:
• Both hypo-Na and hyper-Na are serious risk factors.
• HF and hypo-Na:
– RAAS-activity increases despite volume overload
– AVP increases
– SNS increases
– Clearance free-water impaired
• HF and hyper-Na
• Elderly, frail
• Diet, Thirst
• Loop diuretics
treatment of heart failure and it’s renal consequences
water
solutes
65%
20%
10%
5%
Na, %
all diuretics but spironolactone
work in the lumen
commonly prescribed diuretics
ter Maaten et al. Nat Rev Cardiol 2015
>30% of HF have “[loop–] diuretic resistance”the so-called braking phenomenon
u[Na]ATII, aldosterone
furosemide,
bumetanide
measureu[Na],u[K]
Braking phenomenon
• Dose more frequently, or add thiazides
how to manage [loop–] diuretic resistance?
ter Maaten et al. Nat Rev Cardiol 2015
IV administration
HCT[!]K+ sparing agents
bumetanide[!]also binds to globulins
Pharmacology (loop-)diuretics
• Equipotent dosing
• Switch classes in case no effect probablyuseless (dosing!)
Pharmacology (loop-)diuretics
NB spironolacton: actieve metabolieten T ½ ca. 1½ uur (spironolacton), 9–12 uur (7α–thiomethylspironolacton), 10–35 uur (canrenon)
(loop-)diuretics
• Effect bumetanide 2.5-3 h
• Effect furosemide 4-5 h
• Remaining time is “rebound” = no net negative effect on Na loss
Particularly in case :
- Diuretic response low (Urine Na 24 /K)
- Medication free interval long
- Salt intake
(loop-)diuretics
• Synchronize intake and drug dosing
• - loop diuretic before meals
Slow release less effective?
(loop-)diuretics - therapy
• GFR 15 mL/min:• Only 10-20% furosemide in tubule: so increase
dose
• IV to oral: • bumetanide identical• furosemide 1-10 times (x ceiling dosis 160-250
mg iv)
• Dosing based on effect!
(loop-)diuretics - therapy
• Normal response on 40 mg furosemide (of equivalent bumetanide):
• 200-250 mmol Natrium & 3-4 L urine in 3-4 h.
• Max. response 20-25% filtered Natrium• In case GFR 15 mL/min, then 25 mmol
Natrium per dose.
• So restrict salt intake• Add thiazide
Loop-diuretics – combi thiazides
• Mild KI: 50-100 mg/daY• Severe KI: 100-200 mg/day
• Loading dose? ( T½)• Once a day (T½)
• Severe KI:– more and more often (NYHA II-III 3-4x)
(loop-)diuretics – intravenous
Diuretics - ¿more? (thiazides)
• Predictive:• Urine low Na- High K: distal reabsorption Natrium::> so
####• Urine low Na-low K: less effect
• Add amiloride in stead of triamterene (conversion lower in congested liver), even in addition to spironolacton/eplerenone
What about kidney function?
• Deterioration often acute and hemodynamically, not structural
• Renal autoregulation
• Treat blood pressure
• Treat heart failure and accept kidney function (to certain extent)
the protective effects of RAS blockade
• improved survival [CONSENSUS, SOLVD]
• anti–fibrotic effects[1]
• improved pressure natriuresis[2]
…[1]
[2]van Paassen et al. J Am Soc Nephrol 2001
what about dual blockade? lessons from the ONTARGETONgoing Telmisartan Alone and combined with Ramipril Global Endpoint Trial
ARB and ACEi combined
• additional 2 – 3 mmHg BP reduction
• less proteinuria
[S]AEs, increased prevalence
• acute kidney injury/doubling SCr
• hyperkalemia
Yusuf et al. N Engl J Med 2008
cardiovascular death
AKI in the setting of RAS blockade
Scherpbier et al. Ned Tijdrschr Geneeskd 2010
dehydration
elderly,
atherosclerosis,
NSAIDs
diarrhea,
fever
check for SCr, K
hyperkalemia among HF patients; particularly when SCr >150 mM
Palmer et al. N Engl J Med 2004
Role of renal replacement therapy?
• UF?
• CAPD?
• Data still unclear
PD in CHF
Rationale:
End-stage congestive heart failure is a serious invalidating condition with a poor prognosis and increasing incidence.
Non-randomized observations showed peritoneal dialysis in these patients to improve clinically from NYHA stadium III-IV to as low as NYHA stadium I-II.
A randomized trial is needed to test whether PD improves symptoms in this condition and to find an optimal scheme.
Groningen trial still running , WMT Janssen (Martini hospital)
Conclusion
• Cardio-renal failure is a fascinating clinical challenge
• There is problably no such thing as a “normal kidney or a normal heart” in this perspective, when checking meticulously organ function and structure.
• It is a systemic disease.
• Even closer cooperation between cardiology and nephrology (and immunology) is warranted
Conclusion
• Treatment needs to be guided by deep understanding of underlying (patho)-physiological mechanisms in order to better maintain volume status, organ perfusion, and inhibit ongoing inflammation and fibrosis