Acute Heart Failure, Diuretics: “Cardiorenal Considerations: 5 Pearls Segment” From Core IM With Links To Additional Resources

In addition to today’s resource, please review:

  • Evaluation of Venous Congestion Using Beside Ultrasonography by the Nephrology Consultant: The VExUS Nexus. Abhilash Koratala, MD.  POCUS J. 2022 Feb 1;7(Kidney):17-20. doi: 10.24908/pocus.v7iKidney.15341. eCollection 2022. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF].
    • “Abstract: In patients with heart failure and cardiorenal syndrome, lingering congestion is associated with worse outcomes. As such, titrating diuretic or ultrafiltration therapy based on objective assessment of volume status plays a crucial role in the management of these patients. Conventional physical examination findings and parameters such as daily weight measurement are not always reliable in this setting. Recently, point of care ultrasonography (POCUS) has emerged as an attractive enhancement to bedside clinical examination in assessing fluid volume status. Specifically, Doppler ultrasound of the major abdominal veins gives additional information about end-organ congestion when used in conjunction with inferior vena cava ultrasound. Moreover, these Doppler waveforms can be monitored in real time to gauge the efficacy of decongestive therapy. Herein, we present a case that illustrates the utility of POCUS in the management of a patient with heart failure exacerbation.Keywords: VExUS, POCUS, venous Doppler, point of care ultrasound, heart failure”
  • Links To And Excerpts From “Unifying Fluid Responsiveness and Tolerance With Physiology: A Dynamic Interpretation of the Diamond-Forrester Classification” With A Link To Dr Rola’s Lecture On VExUS
    Posted on February 9, 2024 by Tom Wade MD

Today, I rereviewed this post and reposted to today.

Today, I review, link to, and excerpt from Core IM‘s Cardiorenal Considerations: 5 Pearls Segment. Posted: May 13, 2024
By: Dr. Andrew Ling, Dr. Nayan Arora, Dr. Nicole Bhave and Dr. Shreya P. Trivedi
Graphic: Dr. Rahul Maheshwari
Peer Review: Dr. Larissa Kruger Gomes, Dr. Nisha Bansal

All that follows is from the above resource.

 

Play Podcast in new window

Time Stamp    CME-MOC    Show Notes    Transcript  References

Time Stamps

  • 02:05 Pearl 1: Make sure the renal dysfunction is not from something else
  • 08:47 Pearl 2: Practical tidbits on loop diuretics
  • 18:08 Pearl 3: Assessing diuretic response
  • 27:35 Pearl 4: Approaching diuretic resistance
  • 35:08 Pearl 5: Don’t be afraid of medical therapy because of CKD

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Show Notes

Pearl 1: Make sure the renal dysfunction is actually all cardiorenal!

  • How do you define cardiorenal physiology?
    • Classic Definition:
      • Kidney dysfunction that is related to either a (1) low-flow state and/or (2) renal venous congestion
        • BOTH can independently lead to decreased intrarenal blood flow
        • BOTH can lead to neurohormonal activation → Increased renin-angiotensin-aldosterone system (RAAS) activity
          • These are compensatory mechanisms that initially preserve renal function but can become detrimental when kidney autoregulation can no longer compensate.
        • NOTE: Renal venous congestion is thought to be a larger contributor to kidney dysfunction than low-flow states in most cases of cardiorenal syndrome.
  • How should you think about the differential for a kidney injury in someone with heart failure?
    • Be broad! Multiple processes can happen at the same time
      • Urinalysis findings:
        • Pure cardiorenal syndrome 
          • “Bland” with no protein, blood, granular or other cell casts
            • May have hyaline casts
            • No signs of intrinsic injury!
      • NOTE: Screen for proteinuria in heart failure patients!

Pearl 2: Practical Tidbits on Loop Diuretics

  • What is the “go-to” loop diuretic for someone who is hospitalized for volume overload?
  • What are the differences between loop diuretics?
    • IV formulations:
      • Furosemide vs. Bumetanide
        • No difference in outcomes demonstrated
          • But not largely studied!
        • Bumetanide Considerations:
          • More potent
            • Practitioners may be more comfortable with using higher equivalent doses since bumetanide doses are in the single digits
          • Severe myalgias with IV bumetanide as a continuous infusion
            • Especially with higher doses
            • Unclear if unique to bumetanide or if purely dose-related given furosemide is not typically used at equally high equivalent doses
    • PO formulations:

Pearl 3: Assessing Diuretic Response and Renal Function

*The above link is not open source. Here are other resources on VEXUS that are open source.

  • Evaluation of Venous Congestion Using Beside Ultrasonography by the Nephrology Consultant: The VExUS Nexus. Abhilash Koratala, MD.  POCUS J. 2022 Feb 1;7(Kidney):17-20. doi: 10.24908/pocus.v7iKidney.15341. eCollection 2022. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF].
    • “AbstractIn patients with heart failure and cardiorenal syndrome, lingering congestion is associated with worse outcomes. As such, titrating diuretic or ultrafiltration therapy based on objective assessment of volume status plays a crucial role in the management of these patients. Conventional physical examination findings and parameters such as daily weight measurement are not always reliable in this setting. Recently, point of care ultrasonography (POCUS) has emerged as an attractive enhancement to bedside clinical examination in assessing fluid volume status. Specifically, Doppler ultrasound of the major abdominal veins gives additional information about end-organ congestion when used in conjunction with inferior vena cava ultrasound. Moreover, these Doppler waveforms can be monitored in real time to gauge the efficacy of decongestive therapy. Herein, we present a case that illustrates the utility of POCUS in the management of a patient with heart failure exacerbation.Keywords: VExUS, POCUS, venous Doppler, point of care ultrasound, heart failure”
  • Links To And Excerpts From “Unifying Fluid Responsiveness and Tolerance With Physiology: A Dynamic Interpretation of the Diamond-Forrester Classification” With A Link To Dr Rola’s Lecture On VExUS
    Posted on February 9, 2024 by Tom Wade MD

Pearl 4: How to approach diuretic resistance

  • What is diuretic resistance?
  • Consider…Is something else going on?
    • Diuretics cannot work if they are not reaching the kidney!
    • Some factors to consider:
      • Shock
      • Low-flow state
      • Elevated intra-abdominal pressure (ascites)
  • How can you augment your diuresis?
    • Sequential nephron blockade!
      • Thiazide or Thiazide-Like Diuretics:
        • PO Metolazone vs. IV Chlorothiazide (or Diuril)
        • Alternative adjusts:
          • Hydrochlorothiazide or Chlorthalidone
            • Reasonabe options though more in outpatient setting
            • Commonly used as antihypertensives
            • Acetazolamide
              • Achieves uccessful decongestion and shortening length of stay
                • Without any differences in safety outcomes!
              • In practice: Considered especially in cases of worsening metabolic alkalosis or in COPD
                • Caution when using if there is acidosis or serum bicarbonate is low!
          • Acute SGLT2i
          • Hypertonic saline
            • Not well-established adjunct
  • What should be monitored during diuresis?
    • Electrolytes, particularly hypokalemia
      • More common with augmentation
      • Hypokalemia is an independent risk factor for development of diuretic resistance
        • Add potassium-sparing diuretics early!
          • Long-term benefit
    • Rapid Volume Depletion
  • What about ultrafiltration (UF)?
    • CARRESS-HF Trial
    • In practice: UF only after a failing maximal medical therapy
      • Due to concerns about future renal function when starting HD and dialysis access complications

Pearl 5: Don’t be afraid of medical therapy because of CKD

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