Assessing continuous renal replacement therapy as a rescue strategy in cardiorenal syndrome 1

Prognosis of Patients with Acute Kidney Injury due to Type 1 Cardiorenal Syndrome Receiving Continuous Renal Replacement Therapy

INTRODUCTION

The prognosis of patients with acute kidney injury (AKI) caused by type 1 cardiorenal syndrome (CRS) requiring continuous renal replacement therapy (CRRT) is unclear. We investigated the in-hospital mortality and prognostic factors in these patients.

METHODS

We retrospectively identified 154 consecutive adult patients who received CRRT for AKI caused by type 1 CRS between January 1, 2013, and December 31, 2019. We excluded patients who underwent cardiovascular surgery and those with stage 5 chronic kidney disease. The primary outcome was in-hospital mortality. Cox proportional hazards analysis was performed to analyze independent predictors of in-hospital mortality.

RESULTS

The median age of patients at admission was 74.0 years (interquartile range: 63.0-80.0); 70.8% were male. The in-hospital mortality rate was 68.2%. Age ≥80 years (hazard ratio [HR], 1.87; 95% confidence interval [CI], 1.21-2.87; p = 0.004), previous hospitalization for acute heart failure (HR, 1.67; 95% CI, 1.13-2.46; p = 0.01), vasopressor or inotrope use (HR, 5.88; 95% CI, 1.43-24.1; p = 0.014), and mechanical ventilation at CRRT initiation (HR, 2.24; 95% CI, 1.46-3.45; p < 0.001) were associated with in-hospital mortality.

CONCLUSION

In our single-center study, the use of CRRT for AKI due to type 1 CRS was associated with high in-hospital mortality.

Continuous Renal Replacement Therapy for Hypertension Complicated by Refractory Heart Failure: An Analysis of Safety and Nursing Highlights

Objective

This research is aimed at analyzing the safety profile and nursing highlights of continuous renal replacement therapy (CRRT) for hypertension (HT) complicated by refractory heart failure (RHF).

Methods

Sixty-six HT + RHF patients admitted between March 2018 and December 2021 were enrolled and assigned to two groups: a CRRT group with 33 cases treated with CRRT and a control group with 33 cases intervened by routine treatment. The therapeutic effect and alterations of cardiac function (CF) indexes were observed in both cohorts. Besides, statistics were made in terms of serum B-type natriuretic peptide (BNP), C-reactive protein (CRP) and mean arterial pressure (MAP) concentrations, time of asthma relief, heart rate recovery (HRR), edema resolution, and hospitalization, as well as incidence of adverse reactions (ARs). Finally, pre- and posttreatment psychological quality and pain of both cohorts of subjects were assessed using the self-rating anxiety and depression scale (SAS and SDS) and visual analogue scale (VAS), respectively.

Results

CRRT group exhibited higher overall response rate and better CF than control group (P < 0.05), with lower BNP, CRP, and MAP levels, and shorter time of asthma relief, HRR, edema resolution, and hospitalization (P < 0.05); the incidence of ARs was similar (P > 0.05); for both groups, the scores of SAS, SDS, and VAS reduced statistically after treatment (P < 0.05).

Conclusion

CRRT can effectively improve the therapeutic effect and CF of patients with HT complicated by RHF, to protect the health and safety of patients.

Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 2-management of right ventricular failure)

The single most important factor in improving outcomes in right ventricular (RV) failure is anticipating and recognizing it. Once established, a vicious circle of systemic hypotension, and RV ischemia and dilation, occurs, leading to cardiogenic shock, multi-organ failure, and death. RV dysfunction and failure theoretically can occur in three settings-increase in the pre-load; increase in after load; and decrease in contractility. For patients deemed low risk for the development of RV failure, when it occurs, the correction of underlying cause is the most important and effective treatment strategy. Therapy of RV failure must focus on improving the RV coronary perfusion, lowering pulmonary vascular resistance, and optimizing the pre-load. Pre-load and after-load optimization, ventilator adjustments, and improving the contractility of RV by inotropes are the first line of therapy and should be initiated early to prevent multi-organ damage. Mechanical assist device implantation or circulatory support with extracorporeal membrane oxygenation (ECMO) may be needed in refractory cases.

Outcomes after Acute Peritoneal Dialysis for Critical Cardiorenal Syndrome Type 1

INTRODUCTION

The aim of the study was to demonstrate the outcomes of peritoneal dialysis (PD) in critically ill cardiorenal syndrome type 1 (CRS1).

METHODS

A cohort of 147 patients with CRS1 who received PD from 2011 to 2019 in a referral hospital in Thailand was analyzed. The primary outcome was 30-day in-hospital mortality. Ultrafiltration and net fluid balance among survivors and nonsurvivors in the first 5 PD sessions were compared.

RESULTS

The 30-day mortality rate was 73.4%. Most patients were critically ill CRS1 (all patients had a respiratory failure of which 68% had cardiogenic shock). Blood urea nitrogen and creatinine at the commencement of PD were 60.1 and 4.05 mg/dL. In multivariable analysis, increasing age, unstable hemodynamics, and positive fluid balance in the first 5 PD sessions were associated with the risk of in-hospital mortality. The change of fluid balance per day during the first 5 dialysis days was significantly different among survivor and nonsurvivor groups (-353 vs. 175 mL per day, p = 0.01).

CONCLUSIONS

PD is a viable dialysis option in CRS1, especially in a resource-limited setting. PD can save up to 27% of lives among patients with critically ill CRS1.

Pathophysiology and Therapeutic Approaches to Acute Decompensated Heart Failure

Acute decompensated heart failure (ADHF) is one of the leading admission diagnoses worldwide, yet it is an entity with incompletely understood pathophysiology and limited therapeutic options. Patients admitted for ADHF have high in-hospital morbidity and mortality, as well as frequent rehospitalizations and subsequent cardiovascular death. This devastating clinical course is partly due to suboptimal medical management of ADHF with persistent congestion upon hospital discharge and inadequate predischarge initiation of life-saving guideline-directed therapies. While new drugs for the treatment of chronic HF continue to be approved, there has been no new therapy approved for ADHF in decades. This review will focus on the current limited understanding of ADHF pathophysiology, possible therapeutic targets, and current limitations in expanding available therapies in light of the unmet need among these high-risk patients.

Cardiorenal syndrome: Multi-organ dysfunction involving the heart, kidney and vasculature

Cardiorenal syndrome (CRS) is a multi-organ disease, encompassing heart, kidney and vascular system dysfunction. CRS is a worldwide problem, with high morbidity, mortality, and inflicts a significant burden on the health care system. The pathophysiology is complex, involving interactions between neurohormones, inflammatory processes, oxidative stress and metabolic derangements. Therapies remain inadequate, mainly comprising symptomatic care with minimal prospect of full recovery. Challenges include limiting the contradictory effects of multi-organ targeted drug prescriptions and continuous monitoring of volume overload. Novel strategies such as multi-organ transplantation and innovative dialysis modalities have been considered but lack evidence in the CRS context. The adjunct use of pharmaceuticals targeting alternative pathways showing positive results in preclinical models also warrants further validation in the clinic. In recent years, studies have identified the involvement of gut dysbiosis, uraemic toxin accumulation, sphingolipid imbalance and other unconventional contributors, which has encouraged a shift in the paradigm of CRS therapy.

Short, and long-term mortality among cardiac intensive care unit patients started on continuous renal replacement therapy

PURPOSE

Patients requiring continuous renal replacement therapy (CRRT) are at high risk of death. Predictors of hospital mortality and post-discharge survival in cardiac intensive care unit (CICU) patients requiring CRRT have not been reported.

MATERIALS AND METHODS

Retrospective review of 198 CICU patients undergoing CRRT from 2006 to 2015. Multivariable regression identified predictors of hospital mortality and Cox proportional-hazards identified predictors of post-discharge mortality among hospital survivors.

RESULTS

The indication for CRRT was volume overload in 129 (65%) and metabolic abnormalities in 76 (38%). 105 (53%) subjects died in hospital, with 22% dialysis-free hospital survival. Cardiogenic shock was present in 159 (80%) subjects; 150 (76%) subjects received vasopressors and 101 (51%) subjects required mechanical ventilation. Hospital mortality was similar in cardiogenic and non-cardiogenic causes of CICU admission. Predictors of hospital death included semi-quantitative RV function, Braden score, VIS, and PaO2/FIO2 ratio. Median post-discharge Kaplan-Meier survival was 1.9 years. Predictors of post-hospital death included age, VIS, diabetes, Braden score, semi-quantitative RV function, prior heart failure, and dialysis dependence. The indication for CRRT was not predictive of survival.

CONCLUSION

Mortality is high among CICU patients requiring CRRT, and is predicted by the Braden score, RV dysfunction, respiratory failure and vasopressor load.

Fluid therapy in non-septic, refractory acute decompensated heart failure patients - The cautious role of central venous pressure

PURPOSE

Fluid therapy in congestive acute decompensated heart failure (ADHF) patients might be inappropriate and worsening the prognosis. The aim of our study was to analyze the effect of fluid administration on mortality in non-septic, ADHF patients with reduced ejection fraction.

MATERIAL AND METHODS

We analyzed 41 ADHF consecutive 'cold-wet' patients (mean age 69.3 ± 14.9 years, 27 men, LVEF 22.8 ± 11.1%, lactates 2.2 ± 1.6 mmol/L) without sepsis. At admission central venous pressure (CVP) was measured (17.6 ± 7.2 cm H₂O), and ultrasound examination of inferior vena cava (IVC) was performed (IVC min. 18.6 ± 7.3 mm and IVC max. 24.6 ± 4.3 mm). Moreover, the groups were compared (survivors vs. non-survivors as well as 1st and 4th quartile of CVP).

RESULTS

Altogether 17 (41%) patients died: 16 (39%) during a mean of 11.2 ± 7.8 days of hospitalization and 1 during a 30-day follow up. Patients in the lowest CVP quartile (<13 cm H₂O) had significantly worse in-hospital survival as compared to patients in the highest quartile (>24 cm H₂O), P = 0.012. Higher intravenous fluid volumes within the first 24 h were infused in patients in the lowest CVP quartile as compared to the highest CVP quartile (1791.7 ± 1357.8 mL vs. 754.5 ± 631.4 mL, P = 0.046). Moreover, more fluids were infused in a group of patients who died during a hospital stay and at 30-day follow up (1362.8 ± 752.7 mL vs. 722.7 ± 1046.5 mL, P = 0.004; 1348.8 ± 731.0 mL vs. 703.6 ± 1068.4 mL, P = 0.002, respectively).

CONCLUSIONS

CVP-guided intravenous fluid therapy is a common practice which in high risk ADHF 'cold-wet' patients might be harmful and should rather be avoided. Lower CVP seems to be related with worse prognosis.

Is the mean platelet volume a predictive marker of a high in-hospital mortality of acute cardiorenal syndrome patients receiving continuous renal replacement therapy?

A high mean platelet volume (MPV) level has been demonstrated to predict poor clinical outcomes in patients with cardiovascular disease. However, the relationship between MPV and mortality in patients with acute cardiorenal syndrome (ACRS) is unknown. Therefore, we investigated the predictive value of MPV for in-hospital mortality of patients with ACRS who received continuous renal replacement therapy (CRRT) in this study.We retrospectively analyzed the demographics, etiology, severity of illness, prognosis, and risk factors of ACRS patients who underwent CRRT in our hospital from January 2009 to December 2014. Patients were classified into 2 groups based on the prognosis and timing of CRRT. The receiver operating characteristic curve was used to examine the performance of MPV in predicting in-hospital mortality. Baseline characteristics, clinical, and hematological parameters at CRRT initiation were compared between the 2 groups. Factors influencing in-hospital mortality were analyzed by univariate logistic regression analysis.The median age of patients was 74 years. Acute myocardial infarction was the most common cause of ACRS, followed by acute decompensated heart failure. The in-hospital mortality was 51.4%. Age, number of organ failure, APACHE II score, and MPV in the nonsurvivors were significantly higher than those in the survivors (P < .05). However, the cardiac function and mean arterial pressure were significantly lower in the nonsurvivors (P < .05). The prognosis of the early intervention group was better than the late-intervention group, but no significant difference was found (P > .05). The area under the curve (AUC) for in hospital mortality based on MPV was 0.735. Univariate analysis showed that age, cardiac function NYHA class, number of organ failure, APACHE II score, MAP, MPV, and use of vasopressors were associated with the prognosis of patients (P < .05).These findings suggest that the prognosis of patients with ACRS who received CRRT was poor, and MPV might be useful as a marker for predicting the in-hospital mortality of these patients.

Cardiorenal Syndrome Type 1: Definition, Etiopathogenesis, Diagnostics and Treatment

Cardiorenal Syndrome Type 1 (CRS-1) is defined as an acute worsening of heart function leading to acute kidney injury and/or dysfunction. It is an important cause of hospitalization which affects the diagnosis as well as the prognosis and treatment of patients. The purpose of this paper is to analyze causes that lead to the development of cardiorenal syndrome type 1 and its clinical consequences, as well as to emphasize the clinical importance of its early detection. The clinical studies and professional papers dealing with etiopathogenesis, diagnosis and treatment of cardiorenal syndrome type 1, have been analyzed. The most important role in the occurrence of cardio renal syndrome type 1 is played by hemodynamic mechanisms, activation of neurohumoral systems, inflammation and imbalance between the production of reactive oxygen species (ROS) and nitric oxide (NO). Diagnosis of cardiorenal syndrome type 1 involves biomarkers of acute renal injury among which the most important are: neutrophil gelatinaseassociated lipocalin (NGAL), cystatin C, kidney injury molecule 1 (KIM-1), liver-type fatty acid binding protein (L-FABP), IL-18 and the values of nitrogen compounds in serum. In addition to a pharmacological therapy, various modalities of extracorporeal ultrafiltration are applied in treatment of CRS-1, particularly if there is resistance to the use of diuretic therapy. As opposed to the experimental models, in clinical practice acute renal injury is often diagnosed late so that the measures taken do not give the expected results and the protective role shown in experimental conditions do not give the same results. For all these reasons, it is necessary to analyze the pathophysiology of renal impairment in cardiorenal syndrome as well as detect early indicators of kidney injury that could have clinical benefit and positive impact on reducing the cost of treatment.

Clinical Evaluation of Continuous Renal Replacement Therapy in Combination with Ultrasound-Guided Percutaneous Transhepatic Gallbladder Drainage for Acute Severe Biliary Pancreatitis: a Retrospective Study

BACKGROUND/AIMS

This study aimed to report the clinical efficacy of continuous renal replacement therapy (CRRT) in combination with ultrasound-guided percutaneous transhepatic gallbladder drainage (PTGD) (CRRT+PTGD) in the treatment of acute severe biliary pancreatitis (ASBP).

METHODS

Between January 2010 and January 2016, 40 cases of patients with ASBP who received routine CRRT (CRRT group) and 40 of those who received CRRT+PTGD (CRRT+PTGD group) at the Affiliated Hospital of Qingdao University (Qingdao, China) were retrospectively reviewed. Clinical (including abdominal pain remission time, gastrointestinal decompression time, Intensive Care Unit (ICU) hospital stay, respirator treatment time, and mortality rate), laboratory (white blood cells [WBC], platelet [PLT], procalcitonin [PCT], C-reactive protein [CRP], total bilirubin [TBIL], alanine aminotransferase [ALT], albumin [ALB], and blood lactic acid [Lac]) parameters, various critical disease scores, and incidence of complications after the treatment were compared between the two groups.

RESULTS

Compared with those in the routine CRRT group, patients in the CRRT+PTGD group exhibited significant remission of clinical symptoms (i.e. shorter abdominal pain remission time, gastrointestinal decompression time, respirator treatment time and ICU hospital stay) (all P<0.05), change of laboratory parameters (WBC, PLT, PCT, CRP, TBIL, ALT) (P<0.05), and improvement of various critical disease scores (P<0.05). Moreover, the variation of most of the above parameters after versus before the treatment was greater in the CRRT+PTGD group than in the CRRT group (all P<0.05).

CONCLUSION

CRRT in combination with PTGD is more effective in the treatment of ASBP than CRRT alone.

Continuous Renal Replacement Therapy: Case Vignettes

The most common indication for continuous renal replacement therapy (CRRT) in critically ill patients is acute kidney injury with hemodynamic instability. Typically, the patient has metabolic disturbances and potential or actual fluid overload that require intervention. Certain critical care diagnoses and/or conditions or therapies present unique CRRT management approaches. Case vignettes are used to present the unique management of CRRT in critically ill patients with rhabdomyolysis, heart failure, and respiratory failure requiring extracorporeal membrane oxygenation.

Initiation and Cessation Timing of Renal Replacement Therapy in Patients with Type 1 Cardiorenal Syndrome: An Observational Study

BACKGROUND/AIMS

Renal replacement therapy (RRT) is a rescue therapy for patients with type 1 cardiorenal syndrome (CRS) with poor prognoses. However, the optimal timing for initiation and cessation of RRT remains controversial. The purpose of this study was to determine the optimal timing of initiation and cessation of RRT for patients with type 1 CRS.

METHODS

In this retrospective analysis, patients with refractory type 1 CRS receiving RRT were divided into 3 groups according to weaning from RRT and death within 90 days. Baseline characteristics, underlying heart disease, comorbidities, drug use before RRT, indicators of RRT initiation, and prognosis were compared between the 3 groups.

RESULTS

Fifty-two patients were enrolled, which included 27 males and 25 females with a mean age of 70.7 ± 16.1 years and a 90-day mortality rate of 65.4%. The mean urine output before RRT initiation was 800 mL/ 24 h in the RRT-independent group, 650 mL/24 h in the RRT-dependent group, and 345 mL/ 24 h in the death group (p = 0.021). Additionally, there were obvious differences in fluid balance between the 3 groups (167, 250, and 1,270 mL, respectively, p = 0.016). Patients could be successfully weaned from RRT when urine output was >880 mL and fluid balance volume was <150 mL.

CONCLUSION

The mean fluid balance of survivors was remarkably less than that of the death group at RRT initiation. RRT termination can be considered when urine output is >880 mL/24 h and volume balance is <150 mL/24 h.

Case report: severe bradycardia, a reversible cause of "Cardio-Renal-Cerebral Syndrome"

Background

Cardio-Renal Syndromes were first classified in 2008 and divided into five subtypes. The type 1 Cardio-Renal Syndrome (CRS) is characterized by acute decompensation of heart failure leading to acute kidney injury (AKI). Bradyarrhythmia was not mentioned in the classification as a cause for low cardiac output (CO) in type 1 CRS. Besides, CRS was not previously associated with central nervous system (CNS) injury despite the fact that cardiac, renal and neurological diseases can coexist.

Case presentation

We report the case of a 93-year old diabetic man who presented for obnubilation. He had a slow atrial fibrillation, was not hypotensive and was not taking any beta-blocker. He developed, simultaneously, during his hospitalization, severe bradycardia (<35 beats per minute), oligoanuria and further neurological deterioration without profound hypotension. An ECG revealed a complete atrioventricular (AV) block and all his symptoms were completely reversed after pacemaker insertion. His creatinine decreased progressively afterwards and at discharge, he was conscious, alert and well oriented.

Conclusion

Our case highlights the importance of an early recognition of low cardiac output secondary to severe bradyarrhythmia and its concurrent repercussion on the kidney and the brain. This association of the CRS with CNS injury-that we called “Cardio-Renal-Cerebral Syndrome”–was successfully treated with permanent pacemaker implantation.

[Acute cardiorenal syndromes]

Heart and kidney are closely interacting organs which function interdependently. Organ crosstalk between these two organs is based on humoral regulation and by inflammatory mediators, which are similar to those dominating systemic inflammation syndrome. The close interaction between heart and kidney results in organ dysfunction following both chronic and acute functional impairment of the respective counterpart. These changes are summarized under the term cardiorenal syndrome (CRS) which is subdivided into 5 types. In the setting of emergency medicine and intensive care units, CRS types 1 and 3 are the most common. CRS type 1 is characterized by acute kidney injury (AKI) developing as a consequence of acute heart failure. CRS type 3 is represented by acute cardiac failure following AKI, often occurring as a consequence of nephrotoxins. Diagnosis of CRS should preferably be made on basis of the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for the diagnosis and staging of AKI. The cardiac diagnostic workup should include echocardiography, electrocardiogram (ECG), cardiac enzymes, and brain natriuretic peptide (BNP). The therapeutic approach in CRS is primarily aimed at treating the causative organ dysfunction. In case of CRS type 3 this means ensuring adequate kidney perfusion, cautious fluid management, and avoiding additional nephrotoxins. In case of diuretic resistant fluid overload, early initiation of extracorporeal fluid removal, preferably by renal replacement therapy, should be considered.

Cardiorenal Syndrome Type 1: Renal Dysfunction in Acute Decompensated Heart Failure

OBJECTIVE

To present a review of cardiorenal syndrome type 1 (CRS1).

METHODS

Review of the literature.

RESULTS

Acute kidney injury occurs in approximately one-third of patients with acute decompensated heart failure (ADHF) and the resultant condition was named CRS1. A growing body of literature shows CRS1 patients are at high risk for poor outcomes, and thus there is an urgent need to understand the pathophysiology and subsequently develop effective treatments. In this review we discuss prevalence, proposed pathophysiology including hemodynamic and nonhemodynamic factors, prognosticating variables, data for different treatment strategies, and ongoing clinical trials and highlight questions and problems physicians will face moving forward with this common and challenging condition.

CONCLUSION

Further research is needed to understand the pathophysiology of this complex clinical entity and to develop effective treatments.