cardiorenal syndrome: therapeutic · cardiorenal syndrome: therapeutic approaches-ultrafiltration...
TRANSCRIPT
Cardiorenal syndrome: therapeutic
approaches-Ultrafiltration
Dr Pascaline ALIX Université Claude Bernard Lyon 1
Néphrologie-Hôpital E. Herriot Lyon, FRANCE
Heart failure
• Despite modern heart failure therapy, the prognosis of patients with heart failure remains poor
• Prevalence of chronic kidney disease : 32% • Worsening renal function and mortality
Damman et al, 2013 Mahon et al, 2002
Isolated ultrafiltration
Isotonic ultrafiltrat
HEMOCONCENTRATION
ULTRAFILTRATION
ENTRY
EXIT
FILTER
Hydrostatic pressure gradient
Interstitial sector
Ultrafiltration group
• Stop loop diuretics • UF 200 ml/h • The addition of intravenous vasodilators
or positive inotropic agents after randomization was prohibited
Cardiorenal outcomes after slow continuous ultrafiltration therapy in refractory patients with advanced decompensated heart failure.
- high incidence of subsequent transition to renal replacement therapy
- high incidence in-hospital mortality Patarroyo, JACC 2012
Continuous Ultrafiltration for Congestive
Heart Failure
Patients with congestive HF randomized to receive standard medical therapy or ultrafiltration - a lower incidence of rehospitalizations in the ultrafiltration
group - more stable renal function, unchanged furosemide dose,
and lower B-type natriuretic peptide levels - At 1 year, 7 deaths (30%) occurred in the ultrafiltration
group and 11 (44%) in the control group
Marenzi et al, JCF, 2014
Cicatrisation = 10-15 days Ascites delayed healing infection Anticoagulant Bleeding
Peritoneal dialysis
Ultrafiltration
Osmotic agents - Crystalloid agent - Colloid agent
Peritoneal cavity Capillary lumen Capillary lumen Peritoneal cavity
Blood P 148 urif 2010;30:146–152 European Journal of Heart Failure (2012) 14, 530–539 European Journal of Heart Failure (2012) 14, 540–548
Cohorte Lyon-CARE
Nephrologists and cardiologists
Standardized evaluation
Information: prognosis, therapeutics and levels of evidence
Shared medical decision
Longitudinal follow-up
Lost n=3
Severe heart failure and kidney failure 112 patients
Inclusion criterias: -≥ 2 cardiac decompensations/year
and/or chronic congestion -Furosemide ≥ 250mg 23 patients exclus 89 included patients
86 analyzed patients
Medical treatment without UF
n=54
Information and multidisciplinary approach
UF n=32
Hemodialysis n=19
Peritoneal dialysis n=13
Cohorte Lyon-CARE :
0%
20%
40%
60%
80%
NYHA III-IV (%)
All Medical ttt HD PD 0
10
20
30
40
DFG estimé (ml/min/1,73m2)
All Medical ttt HD PD
Cohorte Lyon-CARE
Medical treatment Hemodialysis Peritoneal dialysis
Cohorte Lyon-CARE
All Medical ttt HD PD (n=86) (n=54) (n=19) (n=13)
CHARACTERISTICS Age (years) 66,3±12,6 66,4±13,7 64,1 (12,1) 68,9 (7,6) Male, n (%) 58 (67,4) 36 (66,6) 14(73,7) 8(61,5) Type 2 diabetes, n (%) 39 (45,3) 25 (46,3) 10 (52,6) 4 (30,7) Hypertension, n (%) 44 (51,1) 31 (57,4) 8 (42,1) 5 (38,5) CARDIAC FUNCTION Decompensation/year 3 ± 1,1 3 ± 1 3,2 ± 1,2 2,8 ± 1,2 FEVG<40%, n (%) 44 (51,2) 28(51,8) 10 (52,6) 6 (46,1) TAPSE (mm) 15,6 ± 5,9 15,6 ± 5,4 16,1 (6) 15,2 (8,3) IC (L/min/1,73m²) 2,1 ± 0,8 1,9 ± 0,8 2,1(0,7) 2,5 (0,8) PAPS (mmHg) 52,9 ± 14,8 50,7 ± 15,9 54,1 (13,7) 53,7 (11,5)
TREATMENT Furosemide/24h (mg) 531 ± 384 488 ± 358 690 ± 430 479 ± 390 Bitherapy diurétics, n (%) 72 (83,7) 47(87) 13(68,4) 12(92,3) Beta blokers, n (%) 58 (67,4) 36(66,6) 11(57,9) 11(84,6) IEC/ARA2, n (%) 47 (54,6) 33(61,1) 6(31,6) 8(61,5)
Ultrafiltration versus medical therapies in the
management of cardiorenal syndrome • Prospective, controlled, open, randomized,
multicentric trial • Primary outcome measure: death and/or
unscheduled hospitalizations • Secondary outcomes measures:
– Survival – Hospitalizations for acute decompensated heart
failure – Evolution to end stage renal disease – Cardiac parameters – Safety – Quality of life
UF-CARE
• Ultrafiltration – Peritoneal dialysis – Hemodialysis – Isolated ultrafiltration
• Enhanced medical treatment
UF-CARE • Inclusion criterias
– Severe heart failure with recurring congestive symptoms and at least one the following criteria :
• At least 2 hospitalizations during the 12 months before the inclusion, whose the latest one was in the 6 months before the inclusion
• Persistent congestive symptoms throughout 30 days before the randomization: dyspnea (class III or IV NYHA), lower limbs edema and/or ascites.
– Diuretic treatment with at least 250mg furosemide per day (or 6mg bumetamide per day)
– Cardiac medical treatment enhanced by the European cardiology society guidance (except intolerance, and/or contraindication)
– Non end stage kidney disease or kidney failure : estimated DFG (CKD-Epi formula) between 20 and 60 mL/min/1.73m² (or DFG estimated between 60 and 90 mL/min/1.73m² with proteinuria and/or hematuria) and urea rate under 50 mmol/L