Download acute heart failure syndrome - Rajiv Gandhi University of Health

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA
BANGALORE
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DR.TARAPATLA SANDEEP
M.D. GENERAL MEDICINE
SREE RAJARAJESHWARI MEDICAL COLLEGE
BANGALORE
KARNATAKA
:
DR.TARAPATLA SANDEEP
S/O T JAYANANDAM
277/A 3CROSS 5MAIN MURTHY NILAYA
BASAWESHWARA BADAWANE
HOSPET,BELLARY DIST
KARNATAKA
SREE RAJARAJESHWARI MEDICAL COLLEGE AND
HOSPITAL.BANGALORE
:
DOCTRINE OF MEDCINE (GENERAL MEDICINE)
:
31th MAY 2012
:
“A STUDY OF CARDIORENAL SYNDROME IN HEART
FAILURE.”
:
6 Brief Resume of the intended work
6.1
Need for the study
Heart performance and kidney function are closely interconnected and a
synergistic relationship exists between these organs. Dysfunction of one
organ often leads to a deterioration of function of the other one. This clinical
entity has been defined as cardio renal syndrome (CRS). Recently, a new
definition of CRS has been accepted and it includes a classification of the
syndrome into 5 separate subtypes.
CRS type 1 or acute CRS is characterized by a rapid worsening of cardiac
function leading to acute kidney injury (AKI). In the United States, more
than 1 million patients present to hospitals with acute decompensated heart
failure (ADHF) every year. Approximately one-third of the ADHF patients
develop AKI as defined by an increase in serum creatinine of ≥0.3 mg/dl. In
patients with cardiogenic shock, the incidence of AKI can exceed 70%.
Furthermore, patients who develop AKI after an acute cardiac event have a
significantly high mortality risk. Baseline chronic kidney disease (CKD),
diabetes, prior heart failure, and initial presentation with hypertension are
established risk predictors for CRS type 1.
6.2
Review of Literature
The term cardio renal syndrome has been variably defined but can be
considered as a state of advanced cardiorenal dysregulation manifest by one
or more of three specific features, including heart failure with concomitant
and significant renal disease, worsening renal function and diuretic
resistance.
TYPE 1 CARDIORENAL SYNDROME:
Is the most common and charecterised by rapid worsening of cardiac
function (pulmonary oedema, acutely decompensated chronic heart
failure, cardiogenic shock and predominantly right ventricular failure)
leading to acute kidney dysfunction. Neutrophilgelatinase associated
lipocalin(NGAL)appears to be one of the earliest marker detected (1)
TYPE 2 (CHRONIC) CARDIORENAL SYNDROME
Is charecterised by chronic abnormalities in cardiac function causing a
progressive renal dysfunction, with a prevalence around 25%.Independent
predictors of worsening renal function include old age, hypertension, dm,
and acute coronary syndromes.(2)
TYPE 3 ACUTE RENO CARDIAC SYNDROME
Less common than type 1 ,is charecterised by abrupt and primary
worsening of kidney function, leading to cardiac-dysfunction(heart failure,
arrhythmia, ischaemia).Based on the RIFLE consenses acute kidney injury
has been identified in 9% of hospital patients and 35% of icu patients.(3)
TYPE 4 CHRONIC RENO CARDIAC SYNDROME
Is charecterised by a condition of primary chronic kidney disease
contributing to decreased cardiac function, ventricular hypertrophy,
diastolic dysfunction, and or /increased risk of adverse cardiovascular
events. According to current diagnostic criteria for chronic kidney disease,
atleast 10% of the general adult population suffers from this major public
health problem.(4)
ADDITIONAL RISK FACTORS FOR CARDIOVASCULAR
DISEASES IN PATIENTS WITH RENAL DISEASE:
Anaemia; dyslipidemia; hyperhomocystenemia; heightened inflammatory
state,elevated hscrp;endothelial dysfunction.
SECONDARY (TYPE 5 )CARDIO RENAL SYNDROME:
Is charecterised by the presence of combined cardiac and renal
dysfunction due to acute or chronic systemic disorder. In the acute setting,
severe sepsis represents the most common and serious condition that can
affect both organs.
ACUTE HEART FAILURE SYNDROME: International
Journal of Nephrology Volume 2011 (2011), discuss the pathophysiology
of AHFS and its contribution to impairment of kidney function. In the
end, there is approach towards the current evidence of therapeutic
strategies in patients with cardiorenal syndrome in AHFS.(5)
CARDIO RENAL FAILURE: Renal impairment in patients with
heart failure is increasingly recognised as an independent risk factor for
morbidity and mortality. In an analysis of patients enrolled in the charm
study ( Candesartan in heart failure assessment of reduction in mortality ,
morbidity).
Hillege et al; showed that the level of renal dysfunction was a potent
independent predictor of death or heart failure admission.(6)
The acute decompensated heart failure national registry(adhere),a large
data base of 105,388 patients with heart failure requiring hospitalization in
the US , reported that 30% had an additional diagnosis consistent with
chronic kidney disease.(7)
Smith et al (8)conducted a systemic review and meta analysis of 16
studies charecterizing the association between renal impairment and
mortality in 80,098 hospitalized and non hospitalized heart failure patients
(1945through may 2005).Renal impairment was defined variably as
cr>1.0, cr clearance or egfr <90 or cystein-c >1.03. A total of 63%
patients had any renal impairment, and 29% had moderate to severe renal
impairment.Adjusted all-cause mortality was significantly increased for
patients with any renal impairment. Mortality worsened incrementally
across the range of renal function, with 15% increased risk for every 0.5
mg/dl increase in cr and 7% increased risk for every 10ml/min decrease in
egfr.(9)
WORSENING RENAL FUNCTION
Several studies have established that >70% of patients will experience
some increase in creatinine during hospitalisation for heart failure, with
approximately 20% to 30% of heart failure patients experiencing an
increase of >0.3mg/dl(10,11).worsening renal function occurs relatively
early in the course of the hospitalisation.(12)
DIURETIC RESISTANCE(DR)
In patients with acute decompensated heart failure associated with volume
over load, initial therapy focuses on sodium and fluid restriction and
diuretics. Diuretic resistance has been defined as persistent pulmonary
congestion with or without worsening function despite attempts at
dieresis.
6.3
Aims and Objectives of the study
This study was done to know the number of patients affected with
cardiorenal syndrome, causative factor or etiology, risk factors, severity and
treatment of cardiorenal syndrome.
7 Materials and methods
7.1
Source of data
50 patients admitted with heart failure and cardiorenal syndrome from the
dept general medicine in Rajarajeswari medical college, Bangalore.
7.2
Methods of collection of data ( including sampling procedure, if any)
SETTING:
This study is to be done in the outpatient department as well as patients
admitted , Rajarajeswari medical college, Bangalore.
Sample size:- 50 cases
Statistical method:- All continous variables were assumed to be
normally distributed and are reported as arithematic mean with their
standard deviation. The fisher’s exact test was used to compare and analyze
the data.
Period of Study:- one year
CRITERIA
Inclusion criteria:
All patients admitted with cardiac failure of any etiology with a duration
of hospital stay more than 24 hours with or without renal dysfunction.
Exclusion criteria:
1: Patients with documented including renal artery stenosis.
2:Patients with diabetic nephropathy (Proteinuria>300mg.24hours)
3:Patients with history of NSAID abuse
4:Serum creatinine >5 mg/dl
5:Patients not satisfying above criteria (hospital stay <24 hours)
Study design: This study is a prospective cross sectional observational
study.
7.3
Does the study require any investigation or intervention to be conducted on
patients or other humans or animals? if so please describe briefly:
 CBC (TC,DC,ESR,HB,PCV,PLATELETS);
 RFT(BLOODUREA,CREATININE,CREATININECLEARENC);
 SERUM ELECTROLYTES;
 FBS,PPBS;
 LIPID PROFILE;
 URINE ROUTINE –ALBUMIN,SUGAR AND MICROSCOPY;
 ECG;
 CHEST X RAY;
 ECHO;
 ULTRASOUND ABDOMEN AND PELVIS;
 THYROID FUNCTION TESTS.
7.4
Has ethical clearance been obtained from your institution in case of 7.3?
Yes. Ethical clearance has been obtained from “Ethical clearance
committee” of the institution.
8 List of References
(1)MISHRA J ,MA Q , PRADA A ,ET EL .IDENTIFICATION OF NEUTROPHIL
GELATINASE ASSOCIATED LIPOCALIN AS A NOVEL EARLY URINARY
BIOMARKER FOR ISCHEAMIC RENAL INJURY.J AM SOC NEPHROL.2003 ;14:25342543
(2)FORMAN DE , BUTLER J ,WANG Y ,ET EL .INCIDENCE ,PREDICTORS AT
ADMISSION,AND IMPACT OF WORSENING RENAL FUNCTION AMONG
PATIENTS HOSPITALIZED WITH HF . J AM COLL CARDIOL .2004;43:61-67
(3)UCHINO S,BELLOMO R ,GOLDSMITH D ,BATES S ,RONCO C .AN ASSESSMENT
OF THE RIFLE CRITERIA FOR ACUTE RENAL FAILURE IN HOSPITALIZED
PATIENTS . CRIT MED CARE 2006;34:1913-1917
(4)CORESH J, ASTOR BC, GRENE T EKNOYON G ,LEVEY AS .PREVALENCE OF
CKD AND DECREASED KIDNEY FUNCTION IN THE ADULTS US
POPULATION:THIRD NATIONAL HEALTH AND NUTRITION EXAMINATION
SURVEY . AM J KIDNEY DISEASE .2003 ;411-412
(5)INTERNATIONAL JOURNAL OF NEPHROLOGY
VOLUME 2011 (2011),
ARTICLE ID 293938, 10 PAGESDOI:10.4061/2011/293938
(6)HILLEGE HL , NITSCH D , PFEFFER MA,ET AL:RENAL FUNCTION AS A
PREDICTOR OF OUTCOME IN A BROAD SPECTRUM OF PATIENTS WITH HF
.CIRCULATION 2006 ;113 :671-678
(7)ADAMS K F Jr,FONAROW GC,EMERMAN CL,et al:CHARECTERISTICS AND
OUTCOME OF PATIENTS HOSPITALIZED FOR HEART FAILURE IN THE UNITED
STATES :RATIONAL,DESIGN,AND PRELIMINARY OBSERVATIONS FROM THE
FIRST 100,000 CASES IN THE ACUTE DECOMPENSATED HEART FAILURE
NATIONAL REGISTRY(ADHERE).Am heart j 2005 ;149:209-216
(8)SMITH GL,LICHTMAN JH,BRACKEN MB,et al:RENAL IMPAIRMENT AND
OUTCOMES IN HEART FAILURE:SYSTEMIC REVIEW AND META-ANALYSIS.J Am
Coll cardiol 2006;47:1987-1996
(9) SMITH GL,LICHTMAN JH,BRACKEN MB,et al:RENAL IMPAIRMENT AND
OUTCOMES IN HEART FAILURE:SYSTEMIC REVIEW AND META-ANALYSIS.J Am
Coll cardiol 2006;47:1987-1996
(10)OWAN TE,HODGE DO,HERGES RM,et al:SECULAR TRENDS IN RENAL
DYSFUNCTION AND OUTCOMES IN HOSPITALIZED FAILURE PATIENTS.J Card
Fail 2006;12:257-262
(11)FORMAN DE,BUTLER J,WANG Y,ET AL:INCIDNCE,PREDICTORS AT
ADMISSION,AND IMPACT OF WORSENING RENAL FUNCTION AMONG
PATIENTS HOSPITALIZED WITH HEART FAILURE.J Am Coll Cardiol 2004;43:61-67
(12)GOTTLIEB SS,ABRAHAM W , BUTLER J,et al:THE PROGNOSTIC IMPORTANCE
OF DIFFERENT DEFINITIONS OF WORSENING RENAL FUNCTION IN
CONGESTIVE HEART FAILURE.J Card Fail 2002;8:136-141
9. SIGNATURE OF THE CANDIDATE
10.REMARKS OF THE GUIDE
11.1 NAME AND DESIGNATION OF THE
GUIDE
DR.CHIKKANANJAIAH.R
PROFESSOR OF MEDICINE
RAJARAJESHWARI MEDICAL COLLEGE
AND HOSPITAL
BANGALORE-74
11.2 SIGNATURE OF THE GUIDE
11.3 HEAD OF THE DEPARTMENT
DR.KRISHNA
PROFESSOR AND HOD IN DEPT OF
MEDICINE
RRMCH,BANGALORE.
11.4 SIGNATURE OF THE H.O.D
12.1 REMARKS OF THE CHAIRMAN AND
PRINCIPAL
12.2 SIGNATURE OF THE
PRINCIPAL