Novel Approaches for Recognition and Management of Life Threatening Complications of AKI and CKD: Focus on Acute Cardiorenal Syndromes

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1 Novel Approaches for Recognition and Management of Life Threatening Complications of AKI and CKD: Focus on Acute Cardiorenal Syndromes Peter A. McCullough, MD, MPH Baylor University Medical Center, Dallas TX USA

2 Five Cardiorenal Syndromes Cardiorenal Syndrome (CRS) General Definition: A pathophysiologic disorder of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction in the other organ CRS Type I (Acute Cardiorenal Syndrome) Abrupt worsening of cardiac function (e.g. acute cardiogenic shock or decompensated congestive heart failure) leading to acute kidney injury CRS Type II (Chronic Cardiorenal Syndrome) Chronic abnormalities in cardiac function (e.g. chronic congestive heart failure) causing progressive and permanent chronic kidney disease CRS Type III (Acute Renocardiac Syndrome) Abrupt worsening of renal function (e.g. acute kidney ischaemia or glomerulonephritis) causing acute cardiac disorder (e.g. heart failure, arrhythmia, ischemia) CRS Type IV (Chronic Renocardiac Syndrome) Chronic kidney disease (e.g. chronic glomerular disease) contributing to decreased cardiac function, cardiac hypertrophy and/or increased risk of adverse cardiovascular events CRS Type V (Secondary Cardiorenal Syndrome) Systemic condition (e.g. sepsis) causing both cardiac and renal dysfunction

3 Recognition of Cardiorenal Syndrome

4 Exclude Transient Hemodynamic Cr UO Anticipate, Prevent, and Manage Complications

5 Outline Community versus hospital-acquired Pulmonary congestion and respiratory failure RAAS inhibition Hyperkalemia Conclusions

6 Outline Community versus hospital-acquired Pulmonary congestion and respiratory failure RAAS inhibition Hyperkalemia Conclusions

7 N=718 AKI from Veterans Admininstration Review of Serial Cr 78% Community-acquired (RIFLE Applied over 3 months) 22% Hospital acquired (RIFLE in-hospital)

8 Talabani B, Zouwail S, Pyart RD, Meran S, Riley SG, Phillips AO. Epidemiology and outcome of community acquired acute kidney injury. Nephrology. 2014;19(5): Department of Biochemistry and Immunology, Cardiff and Vale University Health Board, University Hospital of Wales, Cardiff UK and Department of Medical Biochemistry, School of Medicine, Alexandria University, Egypt.

9 Among 11,683 qualifying AKI hospitalizations, 2954 patients (25%) were hospitalized with recurrent AKI within 12 months of discharge. Median time to recurrent AKI was 64 days.

10 Outline Community versus hospital-acquired Pulmonary congestion and respiratory failure RAAS inhibition Hyperkalemia Conclusions

11 Azarbar S, Dupuis J. Lung capillary injury and repair in left heart disease: a new target for therapy? Clin Sci (Lond) Jul;127(2): doi: /CS Review. PubMed PMID:

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13 Meta-Analysis of BNP-Guided Management Trials In 6 randomized controlled trials in patients with heart failure, BNP-guided therapy reduced mortality significantly vs. usual care (HR 0.69 (95% CI ) Troughton STARBRITE STARS-BNP BATTLESCARRED TIME-CHF PRIMA Combined Relative Risk Felker GM et al. Am Heart J. 2009;158:

14 The CardioMEMS HF System is an FDAapproved heart failure (HF) monitor for patients with class III and IV HF

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17 Diuretic Strategy Unguided (inpatient bolus/infusion): No improvement in outcomes DOSE HF Trial ROSE HF Trial Palazzuloli Trial Guided (clinic, oral): -Biomarkers -PA pressure Reduced hospitalization/death 6 Biomarker Trials Felker 2009 CHAMPION Trial PA Pressure monitor 2011

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19 Early Benefit Late No Benefit

20 Risk of Cardiorenal Syndrome Volume Depletion Diuretics Ultrafiltration Diseased Hypotension Heart Tachycardia Shock Organ Hypoperfusion Oliguria Normal Heart Fluid Balance Management Window At-Risk Kidneys Volume Overload Liberal Intake Positive Balance Hypertension Peripheral Edema Impaired Oxygenation Organ Congestion Normal Kidneys Volume Depletion Arterial Underfilling Optimal Status Acute Decompensation Low Blood Pressure High

21 Outline Community versus hospital-acquired Pulmonary congestion and respiratory failure RAAS inhibition Hyperkalemia Conclusions

22 Compelling Evidence for End Organ Benefit 1-6 Role of Angiotensin II in the Progression of Cardiovascular Disease Brain Atherosclerosis Vasoconstriction Vascular inflammation and hypertrophy Endothelial dysfunction Stroke Hypertension Angiotensin II Vessels Heart Left ventricular hypertrophy Fibrosis Remodeling Apoptosis Progression of Heart Failure Death Kidney Glomerular capillary pressure Proteinuria Progression Aldosterone release Glomerular sclerosis of CKD Renal Fibrosis 1. Adapted from Willenheimer R, Dahlöf B, Rydberg E, Erhardt L. Eur Heart J. 1999;20: Dahlöf B. J Hum Hypertens. 1995;9(suppl 5):S37-S Fyhrquist F, Metsärinne K, Tikkanen I.. J Hum Hypertens. 1995;9(suppl 5):S19-S Booz, Baker KM. Heart Fail Rev. 1998;2: Beers MH, Berkow R, eds. In: The Merck Manual of Diagnosis and Therapy. 1999: Anderson S. Exp Nephrol. 1996;4(suppl 1): angiotensin I, angiotensin II 22

23 RAASi: Benefit to Risk Balance Renal Function Stable Compelling Indication for RAASi Post-MI low LVEF or HF Progressive HF Progressive CKD with proteinuria Renal Function Unstable Risk AKI, Risk K Less compelling Indication for RAASi HTN ASCVD Stage 5 CKD Full Court Press Monitor carefully Look forward to new agents for potassium control Select Away from RAASi Still have to monitor carefully Use fall back drugs with less efficacy Expect poor outcomes 23

24 Campanacci L, Fabris B, Fischetti F, Bardelli M, Vran F, Carretta R. Ace inhibition in renal disease: risks and benefits. Clin Exp Hypertens. 1993;15 Suppl 1: Review. PubMed PMID: ACE/ARB Efferent Arterial Tone

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27 K > 6.0 meq/l that required ED visit or hospitalization

28 Outline Community versus hospital-acquired Pulmonary congestion and respiratory failure RAAS inhibition Hyperkalemia Conclusions

29 Severe Hyperkalemia ( 6.5 meq/l) 36% on chronic ACE, ARB, or MRA 22% had AKI with baseline normal egfr 52% had AKI superimposed on CKD 20% presented with cardiac arrest 31% in-hospital mortality Acute kidney injury (AKI) in patients with normal baseline renal function was a strong predictor of mortality, compared with AKI superimposed on CKD.

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31 Outline Community versus hospital-acquired Pulmonary congestion and respiratory failure RAAS inhibition Hyperkalemia Conclusions

32 Conclusions Community acquired AKI is common and approaches for detection are needed Pulmonary congestion is part of the cardiorenal syndrome and may contribute to chronic lung disease There is a very narrow management window on intravascular volume guided diuretic management can benefit RAAS agents are a cornerstone of chronic therapy for CKD and HF, but have hazards in the acute setting Severe hyperkalemia is a consequence of AKI and with new therapeutic agents may be preventable and better managed