ΝΕΦΡΙΚΗ ΑΝΕΠΑΡΚΕΙΑ ΚΑΙ ΚΑΡΔΙΑ

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1 ΝΕΦΡΙΚΗ ΑΝΕΠΑΡΚΕΙΑ ΚΑΙ ΚΑΡΔΙΑ ΙΩΑΝΝΗΣ Ν ΒΛΑΣΕΡΟΣ ΚΑΡΔΙΟΛΟΓΙΚΟ ΤΜΗΜΑ ΙΠΠΟΚΡΑΤΕΙΟ Γ.Ν. ΑΘΗΝΩΝ

3 ΕΙΣΑΓΩΓΗ H χρόνια νεφρική ανεπάρκεια έχει σηµαντική επίπτωση στον γενικό πληθυσµό και είναι παρούσα σε µεγαλύτερο αριθµό ασθενών απ ότι έχει αναγνωρισθεί. Αποτελεί ανεξάρτητο παράγοντα κινδύνου στην εξέλιξη των καρδιακών παθήσεων. Οι καρδιαγγειακές παθήσεις αποτελούν την πρώτη αιτία θανάτου του νεφροπαθούς ασθενούς.

4 Cardiovascular Disease Mortality General Population vs. ESRD Patients Annual CVD Mortality (%) >85 GP Male GP Female GP Black GP White Dialysis Male Dialysis Female Dialysis Black Dialysis White GP: General Population. Age (years) Foley RN, et al. Am J Kidney Dis. 1998;32:S112-S119.

7 ΕΠΙΠΤΩΣΕΙΣ ΤΗΣ ΝΕΦΡΙΚΗΣ ΑΝΕΠΑΡΚΕΙΑΣ ΣΤΗΝ ΚΑΡΔΙΑ Aσβεστοποίηση στεφανιαίων αρτηριών Καρδιακή ανεπάρκεια Βαλβιδοπάθειες Αρρυθµίες

8 ΝΕΦΡΙΚΗ ΑΝΕΠΑΡΚΕΙΑ ΚΑΙ ΣΤΕΦΑΝΙΑΙΑ ΑΝΕΠΑΡΚΕΙΑ Ασβέστωση των στεφανιαίων αρτηριών. Η τροπονίνη αποτελεί τον προτιµητέο βιοδείκτη της διάγνωσης του οξέως εµφράγµατος του µυοκαρδίου. Η νεφρική ανεπάρκεια είναι µείζων προγνωστικός παράγων θνησιµότητας στο οξύ στεφανιαίο σύνδροµο

Vascular Calcification and CKD Patient Without CKD

Intimal Calcification Secondary to Atherosclerosis

9 Vascular Calcification and CKD Patient Without CKD Patients With CKD Rib Ca Deposition Vertebra Intimal Calcification Secondary to Atherosclerosis EBCT Indicating Coronary Calcification EBCT=electron beam computed tomography. Medial Calcification Secondary to CKD Raggi P. Clin Nephrol. 2000;54:

Framingham Heart Study: Coronary Artery Calcification (CAC) Increase as GFR Declines *Median CAC (solid lines) and interquartile GFR ranges (boxes) are presented.

10 Framingham Heart Study: Coronary Artery Calcification (CAC) Increase as GFR Declines *Median CAC (solid lines) and interquartile GFR ranges (boxes) are presented. 319 subjects (162men/157 women) from the Framingham Heart Study who were free of symptomatic cardiovascular dise Coronary artery calcification (CAC) was evaluated by electron-beam computed tomography( EBCT) Correlation was significant when adjusting for age, sex, body mass index, hypertension and total cholesterol

11 Risk of Cardiovascular Calcification Mean total coronary artery calcium score* Non-dialysis, no CAD (N=22) Non-dialysis, CAD (N=80) Dialysis (N=49) Age (years) High CV risk *Determined by electron beam computed tomography (EBCT) CAD=Coronary Artery Disease Braun J, Oldendorf M, Moshage W, Heidler R, Zeitler E, Luft FC. Am J Kidney Dis. 1996;27:

14 NEΦΡΙΚΗ ΑΝΕΠΑΡΚΕΙΑ ΚΑΙ ΚΑΡΔΙΑΚΗ ΑΝΕΠΑΡΚΕΙΑ Μηχανισµοί: -Υπερφόρτωση πίεσης συνήθως λόγω υπερτάσεως -Υπερφόρτωση όγκου -Καρδιοµυοπάθεια Πιστοποίηση καρδιακής ανεπάρκειας -GFR<60ml/min/1.73m2 -BNP>200pg/ml

16 ΝΕΦΡΙΚΗ ΑΝΕΠΑΡΚΕΙΑ ΚΑΙ ΒΑΛΒΙΔΟΠΑΘΕΙΕΣ. Ασβέστωση µιτροειδικού δακτυλίου Αορτική σκλήρυνση Βακτηριακή ενδοκαρδίτις (αντικατάσταση της βαλβίδας,υψηλή θνησιµότητα)

17 ΝΕΦΡΙΚΗ ΑΝΕΠΑΡΚΕΙΑ ΚΑΙ ΑΡΡΥΘΜΙΕΣ Αίτια:Ουραιµία,υπερκαλιαιµία,οξείδωση, διαταραχή στην ισορροπία ασβεστίου φωσφόρου. Υπόστρωµα:Yπερτροφία ή διάταση αριστερής κοιλίας,καρδιακή ανεπάρκεια,βαλβιδοπάθεια. Μορφή αρρυθµίας:βραδυαρρυθµία,blocks. Αντιµετώπιση: Διγοξίνη,σοταλόλη,προκαιναµίδη εµφυτεύσιµοι απινιδωτές (υψηλό ουδό)

18 CKD is prevalent in CVD 50 Patients With CKD (%) % 33% 46% 0 CAD CrCl 60 ml/min AMI GFR <60 ml/min CHF GFR 60 ml/min Ix, et al., 2003; Anavekar, et al., 2004; Shlipak, et al., 2004.

19 CKD Predicts CVD Age-Standardized Rate of Cardiovascular Events (per 100 personyr) < 15 Estimated GFR (ml/min/1.73 m2) Go, et al., 2004

20 Cardiovascular Outcomes Worsen with CKD Progression Estimated Event Rate (%) VALLIANT TRIAL 3-Yr Follow-Up by egfr Levels in Post-MI Patients P<0.001 N = 14,527 egfr (ml/min/1.73 m 2 ) <45 Composite End Point Death From CV CausesReinfarction CHF Stroke Resuscitation CHF = congestive heart failure; CV = cardiovascular. Anavekar et al. N Engl J Med. 2004; 351:

21 Relative Risk of Combined CVD by Baseline GFR Group (Adjusted for Age, Race, Gender, BMI, SBP, DBP, HDLcholesterol, LDL-cholesterol, fasting triglycerides, history of * 1.35 * Relative Ris West North 0 GFR90+ GFR60-89 GFR <60 Estimated (egfr) (ml/min/1.73 m 2 ) calculated by simplified MDRD equation * P <0.001 vs. GFR90+

22 Ann Intern Med. 2002;137:

26 CKD and CVD Have One, Screen for the Other!!! Pts with CVD have increased risk for CKD and should be screened annually. Aggressively manage CVD and CKD risk factors and slow progression of two diseases.

27 Early Recognition of CKD and Collaboration between Cardiology and Nephrology Nephrologist Stage Kidney Damage Mild Kidney Function Moderate Kidney Function Severe Kidney Function Kidney Failure egfr Primary Care, Endocrinologist, Cardiologist Adapted from K/DOQI Guidelines For Bone Metabolism and Disease 2003, Bone Care market research.

28 Estimate GFR from Prediction Equations Cockcroft-Gault equation ( CrCl (ml/min) = [(140 age) x IBW (kg)]/(72 x SCr) x (.85 if female) MDRD equation ( GFR (ml/min/1.73m 2 ) = 186 x (SCr) x (age ) x x (0.742 if female) x (1.210) if African-American Cockcroft, DW and Gault, MH.. Nephron. 1976; 16: Levey et al, J AM Soc Nephrol. 2000; 11:155A.

29 NACB Draft LMPG on Emerging Biomarkers of Cardiovascular Disease and Stroke: Recommendation #1 on Markers of Renal Impairment and CVD Risk: CKD Testing, including microalbuminuria and serum creatinine for GFR estimation, should be performed for all individuals with hypertension, diabetes, family history of CKD, and those with CVD or at increased risk of CVD. In addition, measurement of serum creatinine for GFR estimation should be performed for all individuals >65 years old. Individual decision making is recommended for individuals with other CKD risk factors.

30 Glomerular Filtration Rate (GFR) HOW to screen? GFR Best overall index of kidney function in health and disease Normal GFR varies according to age, sex, and body size Normal 120 to 130 ml/min/1.73m 2 in young adults, declines with age Estimate GFR from prediction equations National Kidney Foundation. Am J Kidney Dis.2002; 39(suppl 1): S1-S266..

31 CKD and CVD CKD Patients are in the highest risk group for cardiovascular disease Cardiovascular events are the major cause of morbidity and mortality in CKD patients Early intervention and aggressive treatment is essential Manage traditional CVD risk factors hypertension, cholesterol, smoking, exercise, weight, etc. Manage specific CKD risk factors prothrombotic factors, chronic inflammation,, oxidative stress, etc.

34 National Kidney Foundation. Am J Kidney Dis.2002; 39(suppl 1):S1-S266. Measure Urinary Albumin or Protein Excretion HOW to screen? Untimed, spot urine for albumin- or protein-tocreatinine ratio (first-morning-void preferred) 24- hour urine collection for microalbumin, albumin, or protein acceptable (note: measure creatinine also to determine if collection is accurate) Advantages of random urine vs. 24 hour urine: lower cost and ease of collections

35 NKF-KDOQI Staging Classification of CKD Stage Description GFR 1 Chronic kidney damage with normal GFR > ml/min/1.73 m 2 2 Mild GFR ml/min/1.73 m 2 3 Moderate GFR ml/min/1.73 m 2 4 Severe GFR ml/min/1.73 m 2 5 Kidney failure <15 ml/min/1.73 m 2 or dialysis egfr (ml/min/1.73 m 2 ) * May be normal for age National Kidney Foundation. Am J Kidney Dis. 2002;39(suppl 1):S1-S266.

36 The Cardiorenal Syndrome: Which Came First the Chicken or the Egg? By Elwaleed Elhassan, MD, and Robert Schrier, MD

37 The Cardiorenal Syndrome: Which Came First the Chicken or the Egg? By Elwaleed Elhassan, MD, and Robert Schrier, MD

39 Congestive Heart Failure

40 Congestive Heart Failure Patients with CKD have volume 10-30% increase in volume in absence of edema Palmer, BF, N Eng J of Med, 2002: 347; Common LIFE THREATENING DX!!! (CHF admissions 5x higher in CKD) USRDS, 2004 Annual Report

41 Disturbances of Ca ++, PO 4, PTH, and Vitamin D Decreased Vitamin D Receptors and Ca-Sensing Receptors PTH PTH Ca ++ Bone Disease Fractures Serum P Bone pain Marrow fibrosis Erythropoietin resistance 1,25D Calcitriol Systemic Toxicity CVD Hypertension Inflammation Calcification Immunological Renal Failure Ca = calcium; CVD = cardiovascular disease; P = phosphorus; SHPT = secondary hyperparathyroidism.courtesy of Kevin Martin, MB, BCh.

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