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Bài giảng Managing chronic heart failure patient in chronic kidney disease – BS. Trần Hữu Hiền 1 ManagingChronic Heart Failure Patient in Chronic Kidney Disease BS TRẦN HỮU HIỀN ĐHYK PHẠM NGỌC THẠCH INTRODUCTION 2 Epidemiology Pathophysiology Management Modification of risk factors Diuretic Angiotensin-converting enzyme inhibitors Angiotensin II receptor blockers Beta-blockers Digoxin Oxidative stress and hemodialysis patients 3EPIDEMIOLOGY 4U.S. Renal Data System. USRDS 2012 Annual Data Report: Atlas of ChronicKidney Disease andEnd-Stage Renal Disease in the United States. Bethesda, MD: National Institutes of Health,National Institute of Diabetes and Digestive and Kidney Diseases; 2012 5PATHOPHYSIOLOGYCARDIO-RENAL SYNDROMES (CRS) GENERAL DEFINITION 6Disorders of the heart and kidneys whereby acute or chronic dysfunction in one organmay induce acute or chronic dysfunction of the otherACUTE CARDIO-RENAL SYNDROME (TYPE 1)Acute worsening of cardiac function leading to renal dysfunctionCHRONIC CARDIO-RENAL SYNDROME (TYPE 2)Chronic abnormalities in cardiac function leading to renal dysfunctionACUTE RENO-CARDIAC SYNDROME (TYPE 3)Acute worsening of renal function causing cardiac dysfunctionCHRONIC RENO-CARDIAC SYNDROME (TYPE 4)Chronic abnormalities in renal function leading to cardiac diseaseSECONDARY CARDIO-RENAL SYNDROMES (TYPE 5)Systemic conditions causing simultaneous dysfunction of the heart and kidney House AA, Anand I, Bellomo R, Cruz D, Bobek I, Anker SD, Acute Dialysis Quality Initiative Consensus Group. Defiition and classifiation of cardio-renal syndromes: workgroup statements from the 7th ADQI consensus conference. Nephrol Dial Transplant 2010;25(5):1416–207 8MANEGEMENT Modification of risk factors* 91. Smoking cessation2. Exercise3. Weight reduction to optimal targets4. Lipid modification recognizing5. Optimal diabetes control HbA1C Diuretics 10Major clinical role in reducing fluid overloadin patients with chronic HF and pulmonarycongestion* *Eur Heart J. 2005 Jun;26(11):1115-40. Epub 2005 May 18. Diuretics 11 First-line loop diuretics GFR ≤30 mL/min per 1.73 m2 The dosage of the loop diuretic should be progressively increased until the effective dose is reached Intravenous bolus more effective than oral dose, because bypassing the gastrointestinal tract overcomes impaired drug absorption due to gut edema seen in advanced HF The effective oral or intravenous dose of loop diuretics should be administered as often as needed to maintain the response World J Cardiol 2010 May 26; 2(5): 112-117 Diuretic Resistance 12 Sequential blockade of sodium reabsorption in the nephron can be instituted by administering a distal-acting diuretic, such as hydrochlorothiazide or metolazone, along with a loop diuretic in a dose determined according to the patient’s renal function Continuous intravenous infusion of diuretics may be more effective in resistant cases, prevents the post-diuretic salt retention associated with sequential doses* * J Am Coll Cardiol. 1996 Aug;28(2):376-82. Diuretic Adverse Effects 13 Decrease in renal function Hypovolemia Hypokalemia HyponatremiaAngiotensin-converting enzyme 14 inhibitors Patients with chronic HF, mild-to-moderate renal insufficiency should not be viewed as a contraindication to ACE inhibitor therapy, and a mild and nonprogressive worsening of renal function during initiation of therapy should not be considered an indication to discontinue treatment, as the drug may offer the dual benefit of reducing disease progression in both the heart and the kidney. Arch Intern Med. 2000 Mar 13;160(5):685-93.Angiotensin-converting enzyme 15 inhibitors In patients with moderate or severe renal insufficiency, therapy with low doses of ACE inhibitors should be initiated and the dose should be increased gradually with careful monitoring of renal function ...