Management of CHF + Renal Failure

[SoCuteMD]

Decompensated CHF pt in positive fluid balance. PMHx of 20 yrs uncontrolled DM, recent MI, renal failure secondary to DM.

This patient is admitted to the family medicine service at a small community hospital and I am a fresh off the boards 3rd year - so extremely clueless. In discussing management the team decided to dialyze her since she was maxed out on diuretics and still in positive fluid balance.

Having spent some time at a major teaching hospital in a previous life, I suggested nesiritide. I know it's expensive and I don't know enough to know if it's a better or worse choice than the current plan. I did notice that renal dysfunction is a serious reaction to nesiritide - and for this reason my suggestion was passed over.

I'm just curious - for those of you who use it, where (if anywhere) do you draw the line re: renal function?

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[jayjay1978]

Sounds like Swann to me. Other options might include home pressors (milrinone or dopamine etc) with subsequent progression to HD. Depends if patient might trade quality of life to quantity. As far as nesiritide, that has already died off--studies argue strongly against it.

 

[tum]

sounds like dialysis. also the time frame of the chf matters -- maybe try to chase down the ischemia with a cath if it hasn't been done already.

 

[JayneCobb]

Decompensated CHF pt in positive fluid balance. PMHx of 20 yrs uncontrolled DM, recent MI, renal failure secondary to DM.

This patient is admitted to the family medicine service at a small community hospital and I am a fresh off the boards 3rd year - so extremely clueless. In discussing management the team decided to dialyze her since she was maxed out on diuretics and still in positive fluid balance.

I can't answer your question about Natrecor (and it's not as if I have the qualifications to anyways), but dialysis in this pt is an appropriate choice. Fluid overload alone is an indication for dialysis. And several hospitals I have been in specifically limit Natrecor usage to Cards anyways. Personally, I'd have a hard time justifying a $6000 treatment when dialysis is a little cheaper and gives you a more control on how much fluid you remove.

But one thing you left out in your stem and for curiosity, what is the classification of the pts kidney disease? Acute? Chronic? if so what class? If they are chronic, stage 4 or 5, it may be time to go ahead and start planning for routine dialysis anyways.

 

[MDB0073]

I also agree with getting the patient on dialysis. Also, agreeing with an above post, lets get that heart pumping as much as possible with some epi or dopamine (given that we still have some healthy heart tissue to work with after the MI). Thinking like a future cardiologist, a lot of things are secondary to heart problems. Manage the CHF, possibly fix the kidney failure (given that the DM is under control)

Just my two cents, I'm still just a rookie in the game (MS-2).

Take care.