asmiha 2011 diur resist present

8/13/2019 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


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


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

asmiha 2011 diur resist present

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