CV- nephro combined conference 2012.06.06
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Transcript of CV- nephro combined conference 2012.06.06
報告者: fellow 1 陳筱惠
指導醫師:陳冠興醫師Commented by CV1 張其任醫師
Name: 張 O 嗣 Sex: female Age: 90-year-old Chart number: 487733 Date of admission: 2011/11/18
Persistent dizziness for 1 day
Underlying diseases: chronic kidney disease (stage 4), congestive heart failure, and atrial fibrillation
Dizziness with bradycardia episode at home (HR around 40bpm)
Associated S/S: no palpitation, chest pain, cold sweating, or consciousness disturbance
At ER: clear consiousness, af SVR
Hypertension (BP when OPD follow-up: 180~/70~mmHg)
Heart failure, LVEF:68%, HCVD related, atrial fibrillation rhythm
Chronic kidney disease, stage 4, eGFR: 29.4ml/min, 2011/04/24 crea: 1.64mg/dl
Obstrutive sleep apnea syndrome with restrictive lung
Asthma history Other significant systemic diseases:
denied
Doxazosin 4mg 1# bid Isosorbide-5-mononitrate cr 60mg 1# qd Furosemide 40ng 0.5# qd Aliskiren 150mg 1# qd 2011/06/28~ Exforge (Amlodipine 5mg + Valsartan
80mg) 1# bid 2011/11/15~◦ Micardis Plus (Telmisartan 40mg + HCTZ 12.5mg)
1# qd 2011/10/18~2011/11/15◦ Telmisartan 40mg
Allergy: no known allergy Alcohol: denied; betel-nut: denied;
cigarette: denied Over-the-counter medication or chinese
herb: nil
No family history of malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases
Vital signs: blood pressure: 135/58mmHg; temperature: 36.5‘C; pulse rate: 44/min; respiratory rate: 18/min
General appearance: acute ill looking Eye: conjunctiva: pale, sclera: no icteric Neck: supple, no lymphadenopathy or jugular vein
engorgement Chest: symmetric expansion
breathing sound: bilateral clear heart sound: irregular heart beats, no S3 or S4, no
murmurs Abdomen: soft, flat, no tenderness, muscle guarding, or rebounding liver/spleen: impalpable bowel sound: normoactive Extremities: no lower limb pitting edema Skin: intact, no rash
WBC 6.2x1000/ul
Hgb 8.3 g/dl
Hct 25.4 %
MCV 87 fL
PLT 159 x1000/uL
Segment 78.9 %
BUN 118.1 mg/dL
Creatinine 4.43 mg/dl
GPT 9 IU/L
Na 134 mEq/L
K 8.2 mEq/L
Ca 8.2 mg/dL
Mg 2.3 mEq/L
Tropo - I <0.01 ng/mL
Atrial fibrillation with slow ventricular rate, suspect hyperkalemia induced
Acute on chronic kidney disease, favor ARB drug effect, complicated with hyperkalemia and azotemia
Hypertension, poorly controlled Heart failure, LVEF:68%, HCVD related, atrial
fibrillation rhythm Obstrutive sleep apnea syndrome with
restrictive lung Asthma history
H/D
U/O 2020 660 740 860
BW 55.46 54.8 55.9 56.6
BUN 118.1 58.8
Crea 4.43 2.65
Na 134 138
K 8.5 5.1
Ca
P
C02 21.3
189/88mmHg
141/72mmHg
149/70mmHg
165/79mmHg
U/O 230 1630 2450 350 920
BW 69.5 59.1 58.3
BUN 68.7 73
Crea 2.82 2.45
Na 125 123
K 4.7 5.0
Ca 8.3 8.0
P 4.8 4.5
C02
190/99mmHg
159/72mmHg
186/84mmHg
206/94mmHg
186/89mmHg
Kidney echo
U/O 900 820 400 810 710
BW 57.9 57.2 59.5 60.7
BUN 51 51.4
Crea 1.87 2.63
Na 127 123
K 4.5 4.2
Ca 8.2 7.7
P 2.7 3.0
C02
201/96mmHg
181/80mmHg
145/66mmHg
179/86mmHg
156/72mmHg
Cortisol 14.1Renin 1644Aldosterone 328TSH 0.77Free T4 26.939
U/O 400 1210 700 300 400
BW 61.6 61.1 61.3 62.4
BUN 58.7 63.3 72.8
Crea 2.59 2.31 3.12
Na 123 125 126
K 4.9 5.3 5.6
Ca 8.0 8.0
P 4.7 5.5
C02 15.4 17.3
194/87mmHg
172/79mmHg
172/69mmHg
151/70mmHg
209/86mmHg
U/O 1320 2500 600 300 950
BW 61.6 60 62 62 63.1
BUN 80.4
Crea 2.65
Na 128
K 4.8
Ca 8.2
P 6.0
C02 21.1
179/82mmHg
156/76mmHg
174/84mmHg
169/82mmHg
176/75mmHg
Renin 995
U/O 2180 1400 650 200 600
BW 61.8
BUN 80.7 47
Crea 3.01 2.08
Na 123 130
K 3.9 3.8
Ca 7.9 8.7
P 5.1 2.7
C02
188/84mmHg
193/85mmHg
192/78mmHg
201/95mmHg
210/85mmHg
H/D
U/O 450 700 300 130 90
BW 58.2
BUN 58.1
Crea 3.12
Na 127
K 4.1
Ca 8.4
P 4.3
C02 22.5
203/90mmHg
191/83mmHg
204/90mmHg
174/75mmHg
172/95mmHg
U/O 100 80 150 230 0
BW 58.7
BUN 47.3
Crea 4.78
Na 127
K 4.9
Ca 7.9
P 3.6
C02 24.9
177/81mmHg
178/96mmHg
196/89mmHg
179/88mmHg
202/89mmHg
Hickman implantation
U/O 0 750 650 500 600
BW 54.9
BUN 37.5
Crea 4.83
Na 134
K 4.3
Ca 8.0
P 4.6
C02 23.7
168/74mmHg
164/87mmHg
163/69mmHg
141/74mmHg
168/76mmHg
Renal angiography
U/O 1100 1100 2250 1300 950
BW
BUN 37.9 44.5
Crea 4.92 4.57
Na 131 131
K 4.4 4.5
Ca 7.8 8.5
P 4.9 5.4
C02 23.4 22.6
197/85mmHg
151/69mmHg
168/79mmHg
122/61mmHg
161/74mmHg
Hold H/D
U/O 1450 1400
BW 50.2
BUN 36.5 19.6
Crea 2.83 1.74
Na 133 136
K 4.4 5.0
Ca 9.0 8.6
P 4.2 4.0
C02
147/81mmHg
134/64mmHg
119/54mmHg
1/17 remove hickman
Renal Artery Stenosis: Optimizing Diagnosis and TreatmentProgress in Cardiovascular Diseases 54 (2011) 29–35
1st: atherosclerotic lesions, 90% of all renovascular lesions◦ Typically in older individuals◦ An equal prevalence in men and women◦ Predominantly at or near the origin of the renal
artery and usually are associated with aortic disease
◦ May present with hypertension or renal insufficiency
2nd: fibromuscular dysplasia (FMD)◦ More often in young women◦ Usually associated with hypertension without
renal insufficiency
A limited literature addresses the clinical factors that are predictive of finding atherosclerotic RAS and that may be useful in guiding appropriate screening.
Doppler ultrasound Computed tomography angiography (CTA)
and magnetic resonance angiography (MRA) Conventional angiography
Imaging For Renovascular DiseaseSeminars in Nephrology, Vol 31, No 3, May 2011, pp 272-282
Duplex ultrasonography: screening test◦ Sensitivity: 92.5% to 98%; specificity: 96% to 98%◦ Nontoxic◦ No exposure to ionizing radiation◦ Capable and reliable◦ Major limitation: dependence on technician skill
for acquisition of adequate images; others: obesity, bowel gas, and recent food intake
Computed tomography angiography (CTA):◦ Sensitivity and specificity: > 95%◦ Multicenter Renal Artery Diagnostic Imaging
Study in Hypertension (RADISH) study SEN 64%, SPE 93%
◦ Qualitative◦ Risk of contrast nephropathy
Magnetic resonance angiography (MRA):◦ Slightly lower sensitivities and specificities than
CTA; RADISH study SEN 62%, SPE 84%◦ To measure flow, renal perfusion, and renal
function◦ Poorer spatial resolution, limited availability,
patient tolerance, and the need for extended breath-holding
◦ Nephrogenic sclerosing fibrosis associated with Gadolinium in patients with renal insufficiency
Duplex ultrasonography is inferior to MRA and CTA.
Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis. Ann Intern Med 2001;135:401-411.
Captopril renography:◦ Poor screening test
Dependent on comparative imaging of the right and left kidneys
The incidence of bilateral RAS is approximately 30%.◦ May be useful when trying to determine the
physiologic significance of a known intermediate stenosis
Invasive angiography: gold standard◦ Confirm the diagnosis based on prior noninvasive
testing and with the intent to perform an intervention
◦ The most commonly used methodology: intra-arterial digital subtraction angiography
◦ Complications: related to the vascular access, placement of the guidecatheter into the renal artery, balloon and stent deployment, and contrast administration
◦ Carbon dioxide (CO2) Image quality is reduced. May create greater uncertainty about lesion severity
unless combined with judicious use of iodinated contrast
Medical therapy Revascularization: balloon angioplasty +-
stenting or Surgical bypass or reconstruction
Goals:◦ Blood pressure control◦ Treatment of heart failure and/or pulmonary edema◦ Prevention of nephropathy
Medical therapy Lifestyle interventions:
◦ Dietary recommendations in atherosclerotic RAS: Increased intake of fruits and vegetables, dietary
calcium through low fat dairy products
Angiotensin-converting enzyme (ACE) inhibitors◦ Potential to induce acute hemodynamically
mediated renal failure in patients with RAS◦ Lower cardiovascular event rates (10% vs 13%)
and need for dialysis (1.5% vs 2.5%)◦ The cost of an increased risk of hospitalization for
acute renal failure (1.2 vs 0.6%) Selection bias: patients with better renal function
and/or less severe disease are treated with these agents resulting in an apparent improvement of outcome
Other agents used to control the atherosclerotic process are important for the care of patients with atherosclerotic RAS.◦ Statins: decrease death, limit lesion progression,
and promote restenosis-free survival◦ Platelet inhibitors: prevention of future
cardiovascular events
Revascularization:◦ Balloon angioplasty +- stenting:
Lesion severity, renal function, the skill level of the operators, and complication rates
◦ Surgical bypass or reconstruction: Not benefit over angioplasty High rates of adverse outcomes with surgery,
including perioperative mortality of approximately 10%
When stenting is performed, there are a number of technical factors that should be considered as part of the procedure.◦ “No touch” technique for engaging a catheter into
the renal artery reduce the risk of atheroembolism
◦ No embolic protection device is approved by the Food and Drug Administration for use in the renal artery.
◦ Abciximab (a platelet glycoprotein IIbIIIa inhibitor) ??
A “cure” of hypertension with revascularization◦ < 10% in patients with atherosclerotic RAS◦ Approximately 50% in patients with FMD
Younger patients more likely to achieve this outcome.
Consistent and sustained blood pressure–lowering effect of revascularization
Considerable controversy exists regarding the use of revascularization of atherosclerotic RAS to treat or prevent the development of ischemic nephropathy.◦ Stent revascularization in patients with ischemic
nephropathy and significant stenoses resulted in a slower rate of progression of nephropathy.
◦ In a minority of patients, an actual improvement in renal function is seen with either stenting or surgical revascularization.
FMD: balloon angioplasty◦ In a minority of FMD cases, there will be
concomitant aneurysms of the renal artery. Atherosclerotic RAS
◦ Stenting has proven superior to balloon angioplasty.
Left kidney: 9.9 cm
Right kidney: 7.7 cm
Right renal artery: occluded Left renal artery: proximal 71% stenosis
◦ Balloon dilatation procedures: 56% residual stenosis
◦ Stenting: 5% residual stenosis