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Patient with CHF and acute renal failure

Discussion in 'Critical Care' started by Soleus, 10.04.11.

  1. Soleus

    Soleus

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    Was told of a patient my friend had the other day and was hoping some people on here could shed some light on the issue. He said he had a patient in acute renal failure, creatinine progressively rising, that also had a CHF exacerbation and was several liters up on the hospitalization. My friend said his attending used lasix on the patient, which immediately demonstrated improvement in the renal function and said his attending's rationale was that in an acute decompensated state, the heart and brain will attempt to perfuse at all costs, including vasoconstriction of the kidneys, and by giving lasix, this stimulated perfusion of the renal parenchyma.

    First, from a pathophysiological standpoint is this true and have any of you seen or done this in practice in a similar circumstance? TIA
     
  2. danzman

    danzman The Ace of Spades

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    Had a discussion about this just the other day. Attending favored large dose nitrates, IV ACEi's, low dose lasix and dialysis. He said pretty much the opposite of what you said above, that the lasix would only "open up the spout" if you will, but would play havoc on the lytes and not do anything for the increased SVR. The current tx of acute CHF exacerbation seems to favor less diuretics and more nitrates + ACEi's. My gut tells me that its the dialysis that would make the most sense with ESRF and could buy you some time. Keep the fluids running, give lasix, ACEi and hit them hard with dilators was his approach to these pts.
     
  3. MTGas2B

    MTGas2B Sunny and 70

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    Afterload reduction and getting rid of excess volume (which is really about sodium) are keys in making a failing heart a happy heart. Unhappy (acutely exacerbated) failing hearts can't maintain adequate forward flow. Lack of forward flow can cause acute renal failure, among other things. If the kidney has enough functioning nephrons to dump sodium in response to loop diuretics the water will follow the sodium and volume will be reduced. That hopefully is enough to put the failing heart back in a better place on its starling curve (the failing heart version of the starling curve) which will allow organs get adequate blood flow. That's not an uncommon scenario, acute exacerbation of heart failure, acute renal failure, better with diuretics. Vasodilators are part of that too, nitro, ACE. As the failure gets worse then acute exacerbations might require treatment with inotropes, (which are also vasodilators) like dobutamine, as well.
     
  4. fakin' the funk

    fakin' the funk ASA Member

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    Acute CHF is a low-CO state due to excess preload and poor stroke volume, with resultant elevated SVR. The poor oxygen delivery to the kidneys causes ATN/AKI and poor GFR causes retention of urea/Cr and others. I suppose the remaining (depressed) CO is then diverted to heart/brain but I wouldn't say that's the major issue in a cardiorenal type situation.

    So, diuresis will help with your volume issue, and lasix can potentially lower SVR semi-acutely, along with the other preload/afterload reducers mentioned by others.
     
  5. leviathan

    leviathan Drinking from the hydrant Moderator Emeritus

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    I don't know how many times I've had people look at me like I'm crazy when I suggest giving diuretics to a patient with AKI secondary to decompensated CHF.
     
  6. PMPMD

    PMPMD 4G MD

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    Great topic, thanks for posting. I found a couple nice references for those in training (like me):

    The Clinical Challenge of Cardiorenal Syndrome
    Michael G. Shlipak and Barry M. Massie
    Circulation 2004, 110:1514-1517

    Cardiorenal Syndrome
    Claudio Ronco, Mikko Haapio, Andrew A. House, Nagesh Anavekar, and Rinaldo Bellomo
    J. Am. Coll. Cardiol. 2008;52;1527-1539
     
  7. TrustMe

    TrustMe Junior Member

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    PMPMD, you're my hero. Nice literature search. You must have too much time on your hands.
     
  8. PMPMD

    PMPMD 4G MD

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    Well I AM on a research month.
     
  9. PMPMD

    PMPMD 4G MD

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    That wasn't even a lit search, I did a google search on my iphone while waiting to pick up my wife from the airport.
     
  10. TrustMe

    TrustMe Junior Member

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    HA!!! Awesome.
     
  11. dragonfly99

    dragonfly99

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    Cardiology fellow here:
    -if you have a patient with a history of both chronic kidney disease and CHF, particularly if it's diastolic-only type CHF, the only way to really know the intravascular volume status for sure is to do a right heart cath/Swan. A lot of times we don't have to because if clinically the patient looks volume overloaded, you can just give IV diuretics (assuming there is residual renal function). Dialysis/ultrafiltration is another option particularly if the renal failure is really bad...but a lot of times renal doesn't want to do it unless the potassium or bicarb is bad (acidosis). But sometimes from our point of view dialysis can be indicated just of fix the volume status of the patient, especially if IV diuretics fail.
    -remember that "cardiorenal syndrome" is kind of a garbage pail diagnosis that people use, and there are several different subtypes, if you will...a patient with 10% LVEF in renal failure from cardiogenic shock due to just crappy forward flow is different from a patient with normal LVEF, HTN, some chronic CKD and just diastolic heart failure (the latter is NOT that uncommon)
    -usually ACE-I are not used in the setting of acute kidney injury
    -nitrates are OK but they reduce preload and afterload both
    -if the blood pressure is OK, you can use Isordil/hydralazine, particularly in systolic heart failure (remember, no data to support these for purely diastolic CHF)
    -Nipride is good for pure afterload reduction in bad systolic heart failure...you may need dopamine along with that if the blood pressure sucks...plus dobutamine or milrinone also to help your squeeze...but for pure diastolic heart failure you won't need those
    -I think the original poster's attending just didn't have a good understanding of what goes on with cardiorenal syndromes (or the OP didn't understand what he/she said), because the statement was just not correct...
    -I know Swans/R heart cath has somewhat of the bad name in the critical care community, but in selected cases they can be helpful. Sometimes in a patient with underlying CHF and also underlying chronic renal failure, the only way to figure out wet versus dry (especially if patient is obese or other things make physical exam inaccurate) is to use one
     
  12. dragonfly99

    dragonfly99

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    One thing that can happen when patients are acutely volume overloaded is that the pressure in the renal vein can get high...even if there is some forward flow in the renal artery (i.e. cardiac output is OK) you may not get very good renal perfusion in this situation and diuretics may help you along with excreting your sodium and water.
     
  13. leviathan

    leviathan Drinking from the hydrant Moderator Emeritus

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    My understanding is that a volume overloaded CHF patient still has a low effective intraarterial volume and their stroke volume is decreased because of their far-right position on the starling curve. Diuresing them will shift them to the left on the starling curve and improve cardiac output so that renal perfusion and filtration improves, and that interstitial fluid will become mobilized back into the vascular space.
     
  14. dragonfly99

    dragonfly99

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    Severe systolic heart failure can have a very low cardiac output, but patients with pure or mostly diastolic CHF can go into renal failure also, and they don't have a low cardiac output. There are different types of "cardiorenal" syndrome, and I think the comment above applies only to the type with a low EF (the patient who is cold and blue, EF 5 or 10%, poorly perfusing everything, including the kidneys).
     
  15. europeman

    europeman

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    i don't see the purpose of a swan.

    often times you can get more than enough info with a good bedside cardiac echo

    if they are relatively euvolemic, then an inotrope can often do the trick to get their kidneys perfused and heart working again...
     
  16. MTGas2B

    MTGas2B Sunny and 70

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    I've seen cardiologist place PICCs then use SCVO2 to guide inotrope therapy. Generally in milder CHF exacerbations.
     
  17. jdh71

    jdh71 si vis pacem, para bellum

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    In bad heart patients? :laugh:

    It's not that simple.

    Maybe . . . you're just ask likey to give them v-tach and dump their pressures as help their pump and improve enough forward to flow to reach the beans.

    I've seen plenty of IVCs that don't correlate with jack. The bedside echo is helpful, but can't be used in isolation outside of the complete clinical picture to do anything.

    It's interesting though that we're all going to have get some kind of "credential" to use bedside echo for management in the future. JCAHO is currently visiting my current shop and the are VERY interested in this bedside echo stuff. Any staff using bedside echo for management of critically ill patients better have their credential or it's bad ju-ju.
     

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