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Current & future management of chronic kidney disease
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Rationale
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Cardiorenal syndrome
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first heart, then kidney
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Type 1 acute heart - kidney
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Type 1: acute worsening of heart dysfunction -acute kidney injury (AKI)
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Type 1: acute worsening of heart dysfunction-acute kidney injury (AKI)
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Cumulative all cause mortality in patients with a rise in Cystatin C within 48h after hospitalisation for acute heart failure
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Worsening kidney function in decompensated heart failure:“treat the heart, don‘t mind the kidney“
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Renal impairment in patients with cardiac dysfunction -decreased cardiac output or venous congestion ?
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Comparison of the prognostic usefulness of N-terminal pro-brain natriuretic peptide in patients with heart failure with versus without chronic kidney disease
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GFR from admission to discharge (% change GFR)
- absence or presence of hemoconcentration
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Type 2: chronic heart - kidney
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Type 2: chronic heart dysfunction - progressive chronic kidney disease (CKD)
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Renal function (eGFR) –a predictor of CV death or readmission for CV complications
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In contrast to renal function outcome of heart failure (survival)virtually independent of ejection fraction
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Type 2: chronic heart dysfunction -progressive chronic kidney disease (CKD)
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Cras(Cardiorenal Anemia Syndrome)
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Hospitalised patients with heart failure (OPTIMIZE-HF registry)
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Causes of anemia in heart failure [Cardio-renal anemia syndrome]
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Efficacy and safety of erythropoiesis stimulating agents (ESA) in heart failure
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Prevalence of iron deficiency in patients with heart failure
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Prevalence of iron deficiency in patients with heart failure
impact on survival
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Iron deficiency: an ominous sign in patients with systolic chronic heart failure (prospective observational study)
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Ferric carboxymaltose in patients with heart failure and iron deficiency
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Ferric carboxymaltose in patients with heart failure and iron deficiency
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Type 3: acute kidney - heart
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Type 3: acute kidney dysfunction - acute cardiac dysfunction
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Type 4: chronic kidney - heart
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Frequency of chronic kidney disease in the Netherlands
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Mild reduction of glomerular filtration rate (GFR) associated with increased CV mortality (Hoorn study)
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Mild renal dysfunction associated with incident coronary disease in young males
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Both urinary albumin excretionand eGFR at baseline independently predict CV and renal events
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Risk of CKD (< 60 ml/min/1.73m2) in 281 hypertensive patients after 13 years follow-up according to baseline s-creatinine quartiles within normal range
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Inflammation – # main driving force for adverse outcomes of CV damage indicated by biomarkers e.g. CRP, pentraxin3, IL-6 …
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Baseline S-P predicts 15 years later coronary calcium (EB scan) in 3015 healthy young men (CARDIA study)
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Serum phosphorous and incidence of cardiovascular disease in the community (Framingham offspring study)
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Increasing CV mortality with progressively higher serum phosphate within the normal range –patients with coronary heart disease
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FGF23 (fibroblast growth factor) predicts future cardiovascular events before HD treatment
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FGF23 (but not klotho) increased # LV mass index and # ejection fraction in CKD patients
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Sham
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Diastolic BP on treatment and risk of MI – type 2 diabetic patients with nephropathy (IDNT study)
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Antihypertensive treatment with triple medication
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Consequently when aiming for low blood pressures two caveats
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Asymptomatic or symptomatic coronary artery disease in CKD or ESRD: To treat or not to treat ?
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Prospective data collection non-dialysis dependent kidney disease
and in dialysis dependent CKD
CABG –
survival advantage for all categories of kidney function
PCI –
lower risk of death in dialysis and reference patients compared with no revascularisation
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ENDSTAGE KIDNEY DISEASE
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Survival on hemodialysis- CV events the major cause of death on dialysis
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Stunning – ischemia induced global or regional LV wall
contraction abnormalities and impaired systolic LV function
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Correlation between aortic calcification (AAC) and overall as well as cardiovascular mortality
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Relation between renal function and presentation, use of therapies and in-hospital complications in acute coronary syndrome
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In hospital mortality according to eGFR and admission ECG
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Relation between renal function, presentation and use of therapies in acute coronary syndrome
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Cardiac sequelae of primary kidney disease e.g. glomerulonephritis, polycystic kidney disease…
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Cardiomyocyte hypertrophy and myocardial interstitial fibrosis in uremia –implications for cardiac compliance
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Intramyocardial postcoronary arteries in renal failure
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Ritz-Madrid PACE CV disease 2012 (PPT 11.2MB)
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