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Posts Tagged ‘cardio renal syndrome’

I used to tell my students ,the relationship between the heart and kidney  is so close , it is never justified for  the  two departments of Nephrology and Cardiology  are  physically away by two blocks in our institute .

Kidneys are vital to maintain the volume and pressure of body fluids and heart is responsible for keeping this fluid circulating.

In clinical setting  it is a well known secret ,most deaths in patients who are on dialysis is cardiac while  most  deaths in patients  with CHF are renal.

It remains a mystery  why kidneys were   ever considered as a circulatory organ  , when  our medical pundits de-compartmentalised  human organ systems !

CKD is pre-cardiac failure and CHF is pre-renal failure

The Heart /Kidney affair is so intimate in many  pathological situations both either succeed or fail  simultaneous or sequentially.

While CKD  results in and pressure and volume overload of heart , cardiac failure cause pressure and volume under load (pre-renal  factor) which worsen the renal function and aggravate cardiac function alter.

In essence,  it is vicious cycle of two  serial organs  performing  the vital circulatory function with body fluids playing a  role of diligent mediator.Whenever the kidney  fails heart  is stretched and stressed  to its Frank starling limits by the volume  as well as the accompanying HT load.

While text books link these two organ as simple cardio-renal syndrome it is not happening at the level of patient’s bed side.

Cardiologists and  Nephrologists must realise they need do work in tandem like  their  respective  departmental  organs  which accomplish this task easily !

To tackle this much  maligned  cardio-renal conundrum

Consider CKD as CHF equivalent  and CHF as CKD’s

I would recommend this concept to be infused  right in the third year medical school and  try de- compartmentelise  clinical  medicine.

Need of the hour : How to Moderate ACEI dosing in CKD

ACEI has been a major pharmacological   revolution in controlling and reversing the adverse events of cardiac failure . Some where along ,  a significant fear complex arose regarding the damage it could cause to kidneys.

Recently , we know the role of  ACEI in CKD made U turn(Like what  Beta  blockers did to CHF) .Now, it is presumed ACEI are indeed  safe in most CKD and may  even regress  CKD. Still this concept  has not been fully disseminated  into general physician domain.

Let cardiologist and Nephrologist sit together and sort out this issue.

I guess ,  ACEI controversy is  a sort of  ongoing ego clash  between Nephrologist and Cardiologist . Both like it , both make fuss about it ! In my observation , if  a cardiologist titrate it upwards  Nephrologist would  lower it  and reverse happens if cardiologist express caution about it ! Do you agree ?

Final message

Mankind has  accrued  great benefits  from stunning break throughs in modern medical science . . . but it has come  only at a huge  cost ! Medical knowledge has completely fragmented the physician mind-set .Every good therapeutic concept is  hanging aloof .It requires periodic de-fragmentation (As we do it to our PCs by anti-viral soft ware !)

To begin with , let us  consider   CKD and CHF as single sequential circulatory  entity !

Let us vouch to  create new generation medical professional  devoid of skewed  medical vision !

Reference

Guidelines for ACEI in CKD

NKF national kidnye foundation

https://www.kidney.org/professionals/kdoqi/guidelines_bp/guide_11.htm

acc aha  accf guidelines chf 2013

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This RIFLE  shoots without  bullets . Yes ! it  helps the cardiologist to  trouble shoot  the kidneys which often  suffer from  cath lab cross fires .

As  the cardiologists indulge in sophisticated cardiac procedures ,  in more and  more  sick and co- moribund  patients , it is becoming increasingly  important  for them ,  to   give due  respects  to  other organs as well !

Renal function is an important determinant   in the  over all outcome  in any cardiac patient.

  1. How to assess  the baseline renal function ?
  2. How to measure  the impact  of the  cardiac procedure ?
  3. How to  follow  up and monitor the  progress of  renal function   in coronary  care unit.
  4. How to  reduce the enhanced renal  risk ?
  5. When do you call for  the Nephrology consult ?

Every step becomes  vital . Do not ever think , a  cardiologist’s job is over  once few  stents are deployed . Wheeling   out a  sick  and fragile diabetic  with borderline  creatinine    out of the cath lab  may be  considered   as a procedural success  , but the real success happens only after  every organ of the  your patient  comes  out  unscathed  after the procedure .  In this  context  , we should first aim to  become a nephron  savvy and a nephron friendly cardiologist .

I have witnessed  cardiologists  spend hours  together  in cath lab with liberal injections of contrasts  even in  elderly  who have delicate kidneys .Cardiologist should realise  kidneys are soft and gentle  organs  which unlike the heart  , do not  know  how to cry  (Angina) at times of stress  as they lack  well developed pain fibers  (unmedulated  type c fibers to be precise!) .Only thing they  know  is ( like touch me not plant !)   they  strike work  the next   next morning (What we refer to  technically as Acute renal  shut down !)

Now , we see little  interaction  occurring between a  cardiologist and nephrologist  prior to PCI , even though  those two organs ( The   respective experts behold )  are  constantly in touch  with each other , every minute ,  by neural and hormonal mechanisms. The new generation organ  specialists  has to learn  a lot   from these sincere , interactive  , democratic  human   biological system.

Coronary arteries can gulp any amount of dye but  not the renal  arteries .The   future looks still more frightening ,  as we have a variety of devices lined  up  to invade human vascular tree (TAVI, Renal ablation, per cutaneous aortic pumps etc)

So what should we do ?

  • Patients  prone for  CIN should be promptly  recognized .
  • Ask repeatedly  the question .  Am  I   sure  ?  . . .does this patient  require this  procedure at all ?  If  so , have I taken all the precautions ?
  • Use the nephrologist’s services more liberally

Finally ,  read the basics of  nephrology   lessons  once again .  The international consensus group has  classified   the Acute kidney  injury  (AKI)   with a  simple and lovely criteria  for  risk  triaging .     It is a  five faceted ,  inverted  (Tip less ) triangular  cartoon called  RIFLE .

The beauty of  RIFLE   lies in its  simplicity . All  it requires  is  serum  creatinine   (eGFR)  levels  and urine output.  Let  every  cardiologist  master this scheme of AKI . It will immensely  help  our  patients   and make us  a  complete  physician   instead of   being  labelled as a  “master of  an  organ”   or   ” An accessory sub physician”

The CIN prevention recipe.

Source Catheterization and Cardiovascular Interventions 69:135–140 (2007)

References

For review about Contrast nephropathy (CIN)  there are lots of excellent articles.

One company is trying to find a new  solution for  this complication . Let us welcome it ! The device is called rena  guard .

Renal Guard : A new technology to prevent CIN

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