Download - Asmiha 2011 Diur Resist Present
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the m n gement ofDIURETIC RESISTANCE IN HEART FAILURERully Roesli
Bandung
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DIURETIC RESISTANCE IN HEART FAILURE
The KIDNEY and the HEART drown together
The KIDNEY drown the HEART
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Diuretic Resistance: What is it?
O Inadequate response to diuretic therapy
O Represents an extension of cardiorenal
syndromeO Failure to respond to IV loop diuretics
O Decreased efficacy of diuretics with
prolonged treatment
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Causes of
Diuretic Resistance
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Copyright 2008 American College of Cardiology Foundation. Restrictions may apply.
Ronco, C. et al. J Am Coll Cardiol 2008;52:1527-1539
CARDIO
RENAL SYNDROME
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PATHOPHYSIOLOGY
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VOLUME
OVERLOAD
INCREASED
COP
INCREASED
PERIPHERAL
RESISTANCE
INCREASED
BP
PRESSURE
NATRIURESIS
DIURESIS
NORMALIZE
BODY VOLUME
HEART
FAILURE
NORMAL
KIDNEY
TOTAL BODY AUTOREGULATION
(GUYTON)
normal
physiology
the KIDNEYhelps
the HEARTNORMAL
BP
NORMALIZE
COP
NORMALIZE
PERIPHERAL
RESISTANCE
CARDIORENAL INTERACTIONpoor
perfusion
INTERORGAN COMMUNICATION
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What happens if the HEART& the KIDNEY
didnt communicate well ?
CardioRenal Syndrome
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poorperfusion
VOLUME
OVERLOAD
LOW
COP
R A S
ALDOSTERONE
SNS ACTIVITYNO-ROS dysbalance
Inflammatory mediators
INCREASED
BP
HEART
FAILURE
Clamping downSodium retention
RENAL
FAILURE
INFLAMMATION
CARDIO-RENAL SYNDROME (GUYTON
REVISITED)
ANURI
OLIGOURI
CARDIORENAL CONSPIRATION
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CLINICAL SIGNS
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Risk Factors-Old age
-Low Ejection Fraction-Elevated creatinine level
-Low Systolic Blood Pressure
-Diabetes Mellitus
-Hypertension
-Use of antiplatelet drugs, diuretics,
or beta-blockers
CLINICAL SIGNS of CARDIO ~ RENAL SYNDROME
patient with
ADHF = Acute Decompensated Heart Failure
CHF = Congestive Heart Failure
worsen of RENAL FUNCTION
VOLUME OVERLOAD
RESISTANCE TO DIURETICS
Hyper or hypo- kalemia
Hypomagnesemia
Hyponatremia
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poorperfusion
VOLUME
OVERLOAD
LOWCOP
INCREASED
BP
HEART
FAILURE
Clamping downSodium retention
RENAL
FAILURE
CARDIO-RENAL SYNDROME TARGET OF
TREATMENT
ANURI
OLIGOURI
(VOLUME OVERLOAD)
INFLAMMATION
R A S
ALDOSTERONE
SNS ACTIVITYNO-ROS dysbalance
ULTRAFILTRATIONDIURETICS
ANTI-INFLAMMATION
ANTI- RAAS
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poorperfusion
VOLUME
OVERLOAD
LOWCOP
INCREASED
BP
HEART
FAILURE
Clamping downSodium retention
RENAL
FAILUREANURIOLIGOURI
(VOLUME OVERLOAD)
INFLAMMATION
R A S
ALDOSTERONE
SNS ACTIVITY
NO-ROS dysbalance
DIURETICS ULTRAFILTRATION
ANTI-INFLAMMATION
ANTI- RAAS
CARDIO-RENAL SYNDROME TARGET OF
TREATMENT
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MANAGEMENT
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Managing cardiorenal syndrome: Practical
recommendations.
(1) Restrict fluid and sodium intake
(2) Increase furosemide dose
(3) Use continuous intravenous furosemide
(4) Add thiazides or metolazone
(5) Add renoprotective dopamine at 2
3mcg/kg/min
(6) Add inotrope or vasodilator (according to
systolic blood pressure)(7) Start ultrafiltration
(8) Insert intra-aortic balloon pump
(9) Insert another device
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TARGET OF TREATMENT VOLUME
OVERLOAD
DIURETICS
LOOP DIURETICS
(furosemide)
ORAL
DRIP
(recommended)BOLUS
Diuretic Resistance
-Inadequate dose
-Excess sodium-Delayed absorption
-NSAID
-Renal or Heart failure
THIAZIDES
(HCT)
LFG < 30 cc/mnt
Note : diuretics therapy can worsen renal function
Change to other LD
(bumetanide/torsemide)
Use -type Natriuretic Peptide
(BNP=nesiritides)
Increased oncotic pressure with :
Albumin/Mannitol/ColloidLow-dose Dopamin:
Not recommended
Effect :
-reduce pre/after-load
-natriuresis/diuresis
-suppress norepinephrine, endotelin,
and aldosterone
may increased risk of renal failure
In heart failure patients
NEED MORE INVESTIGATION
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Disadvantages of Conventional
Diuretic Therapy in CHFO Has potential to activate neurohormonal
vasoconstrictor systems
O Can cause electrolyte abnormalities
O Has been associated with increased riskof morbidity and mortality
O Can lead to development of pre-renalazotemia
O May result in diuretic resistance
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Diuretic DosePharmacokinetics of loop diuretics according to the renal function in heart failure
patients. IV: intravenous; CrCl: Creatinine Clearance.
Diuretic CrCl CrCl CrCl75
ml/min ml/min ml/min
Furosemide 80160 160200 4080 40 20 then 40 10 then 20 10
Bumetanide 48 810 12 1 1 then 2 0.5 then 1 0.5
Torsemide 2050 50100 1020 20 10 then 20 5 then 10 5
Moderate renal Severe renal Heart Failure
Insufficiency Insufficiency
Maximal IV dose (mg) IV
Loading
Dose
(mg)
Infusion rate (mg/hr)
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Keberhasilan terapi diuretik dapat diramalkan dari
Warna dan konsentrasi urin
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TARGET OF TREATMENT
INREASED RAAS
Use of ACE-I OR ARB
Start with low dose
Patient not dehydrated
Avoid using NSAID
When using of ACE-I OR ARB beware of : increased creatinin and potassium
BETTER OUTCOME(SOLVD,PRIME-2,CONSENSUS,ELITE)
increased
potassium
increased
creatinine
Combination with
CCB
Combination with
DIURETICS
If contra-
indicated
Hydralazine/
Isosorbid-dinitrates
ISORDIL
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TARGET OF TREATMENT
FUTURE DRUGS
Arginine Vasopressin Receptor Antagonists
(Conivaptan or Tolvaptan)- antagonist the arginine vasopressin secreted by pituitary gland
- results in diuresis and retention of electrolytes
Adenosine A1 Receptor Antagonists
(Conivaptan or Tolvaptan)
- antagonist plasma adenosine
- results in diuresis and natriuresis
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ULTRAFILTRATION
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TARGET OF TREATMENT :
ULTRAFILTRATION
SEVERE VOLUME OVERLOAD
iv DIURETICSDIURETIC
RESISTANCE ULTRAFILTRATION
CRRT SLED
SCUF
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Ultrafiltration in CHF Patients:
Principles and Benefits
O Provides an additional modality for fluid
removal
O Allows for a predictable amount of fluid tobe removed
O Rapidly removes salt and water (up to 500
cc/hr)
O Safer than diuretics because removal ofsalt and water is isotonic
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Use of Ultrafiltration
in CHFO Ultrafiltration can be beneficial in
O Acutely decompensated CHF patients
with obvious volume overload
O Diuretic-resistant patients
O Renally impaired patients
O Hospitalized heart failure patients
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Multidisciplinary Approach to
Successful Adoption of UltrafiltrationO Many departments/personnel should be
educated and involved
O ICU
O IV team
O Nephrologists
O Other cardiologists
O Nurses
O Emergency departmentO Telemetry unit
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HYBRID DIALYSIS
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IHD SLED CRRT
Td (jam) 4-5 612 24
Qb (cc/m) 200-300 100-150 100-150
Qd (cc/m) 500 300 0
UF (/jam) Cepat
(4-5 jam)
Sedang
(6-12 jam)
Lambat
( 24 jam)
IHD CRRT
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Pilihan dialisis baru :
HFR
SLED
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HFR - SLED
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Clinical studies of
Ultrafiltration
In Heart Failure
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Ultrafiltration versus IV Diuretics for Patients
Hospitalized for Acute Decompensated CongestiveHeart Failure (UNLOAD) Trial
O Prospective, randomized trial comparingultrafiltration and aggressive IV diuretic
therapy in acutely decompensated HFpatients
O Patients had to have 2 signs of volumeoverload, be randomized within 24 hoursof admission, be hemodynamically stable,and have no prior treatment with IVvasoactive drugs
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UNLOAD:
Primary Endpoint Results
O At 48 hours, significantly greater amount
of weight loss seen with ultrafiltration (5 kgvs 3.1 kg) as compared to IV diuretics
O Dypsnea scores significant and similar in
both groups
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UNLOAD:
Secondary Endpoint Results
O Net fluid loss at 48 hours greater inultrafiltration group than standard care
groupO At 90 days, ultrafiltration resulted in
O 48% in % of patients requiring re-hospitalizations for HF
O 53% in absolute # of re-hospitalizations
O 62% in length of re-hospitalizations
O 53% in # of emergency department orunscheduled office visits for HF
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Ultrafiltration Versus Usual Care forHospitalized Patients With Heart Failure
The Relief for Acutely Fluid-Overloaded Patients
With Decompensated Congestive Heart Failure(RAPID-CHF) Trial
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Relief for Acutely Fluid-Overloaded Patientswith Decompensated Congestive Heart Failure
(RAPID-CHF) Trial
O Multicenter, randomized trial comparing
the effects of ultrafiltration (n = 20) to
usual care (n = 20) in hospitalized patients
with decompensated HF
O Early ultrafiltration was well-tolerated and
resulted in significantly greater weight loss
and net fluid removal compared to usual
care
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Results
Bart et. al. JACC 2005;46:2043-2046 (n=40)
Fluid removal after 24 h was 4,650 ml and 2,838 ml in the
UF and usual care groups, respectively (p = 0.001)
Compared to usual care, UF was not associated withsignificant changes in heart rate, blood pressure, or
electrolytes
Dyspnea and CHF symptoms were significantly improved
in the UF group compared to usual care at 48 h
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Conclusion
Bart et. al. JACC 2005;46:2043-2046 (n=40)
The early application of UF for patients with
CHF was feasible, well-tolerated, and resulted
in significant weight loss and fluid removal.
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Early Ultrafiltration in Patients with Decompensated HeartFailure and Observed Resistance to Intervention with Diuretic
Agents (EUPHORIA) Trial
O Single center, prospective trial (n = 20)comparing the safety of reducing length ofhospitalization by early ultrafiltration
compared with IV diuretics and/orvasoactive drugs in decompensated CHFpatients with diuretic resistance
O Early ultrafiltration decreased hospitallength of stay and number of re-hospitalizations; clinical benefits sustainedup to 90 days
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Conclusion In heart failure patients with volume overload and diuretic resistance,
UF before IV diuretics effectively and safely decreases length of stayand readmissions.
Clinical benefits persist at three months.
A treatment strategy of early UF may decrease length of stay andrehospitalizations in high-risk heart failure patients.
Early UF may be an alternative to reserving UF for patients refractoryto all other pharmacologic strategies.
A prospective randomized study comparing UF with standardtherapy for ADHF to identify effects specifically attributableto UF (UNLOAD) is complete and awaiting publication 2006.
Costanzo et. al. JACC 2005;46:2047-2051 (n=20)
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Circ Heart Fail 2009 ;2
SEMOGA BERMANFAAT
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H TURNUHUN
SEMOGA BERMANFAAT