Cor Pulmonale, CKD/AKI and Cardiorenal Syndrome

Sept 25, 2015

Definitions Pulmonary HTN is defined as mean

pulmonary artery pressure of > 25 mm Hg (as seen on echo)

Causes of Pulmonary HTN include: • PE, COPD, primary Pulm HTN, CHF, OSA, ILD

As Pulm HTN progresses, it alters the structure of the right ventricle and causes Cor Pulmonale

Pulmonary Heart Disease and Cor Pulmonale are synonymous

Definitions Cor Pulmonale causes chronic right sided

diastolic heart failure It is critical to understand when Cor

Pulmonale becomes acute as this condition can be life threatening (e.g. pulmonary embolus)• Synonymous terms

Acute Cor Pumonale Acute pulmonary heart disease Pulmonary HTN with acute right heart strain (failure)

Suspect Acute Cor Pulmonale when:

There is underlying documented chronic lung disease such as COPD, OSA, ILD

There is an acute exacerbation of shortness of breath and the following findings:• Elevated JVP, peripheral edema and ascites• EKG with S1Q3 pattern• RVH/RV strain on echo• Blood work includes an elevation of BNP

When to query for Acute Cor Pulmonale?

Query when the patient presents with acute on chronic dyspnea in setting of known COPD, OSA or ILD

PMH includes pulmonary HTN (usually dx’ed by echo with elevated pulm arterial pressures)

Lung exam has no wheezing but rather crackles, BNP is elevated and echo shows a normal LV size and function but dilated/hypertrophied RV

It will be a slam dunk if echo shows: “right heart strain” (RV dilatation and RV systolic dysfunction)

When to query for Acute Cor Pulmonale?

If you see the following terms in the chart:• Pulmonary HTN, RVH, RV failure/dysfunction, right

heart failure, right heart strain Any admission for PE with elevated BNP,

should be queried about acute cor pulmonale!

Any admission for severe COPD exacerbation without acute respiratory failure (no hypoxemia/hypercapnia) but with elevated BNP, JVD and echo evidence of right heart strain

Chronic Kidney Disease

Chronic Kidney Disease Estimated GFR calculated:

• MDRD formula

• Cockcroft-Gault formula Used to calculate renal

medication adjustment Assumes stable creatinine

Acute Kidney Injury National Kidney Foundation

Definition:• Increased creatinine ≥ 0.3 mg/dL (levels

obtained within 48 hours)• Increased creatinine ≥ 1.5 x baseline within

prior 7 days• Urine volume of less than 0.5 cc/kg/h ≥ 6

hrs Note absolute creatinine has nothing

to do with definition of AKI

Acute Kidney Injury Pre-renal acute kidney injury Intrinsic Renal acute kidney injury

• ATN Post renal acute kidney injury

Acute Kidney Injury: ATN Higher level severity than AKI 1/3 of all causes of AKI in hospitalized

patients Due to:

• Hypotention• Meds (contrast)

Urine often bland (like with pre-renal AKI) Fractional Excretion Na+ (FENA) > 2% Recovery ≥ 3 days (pre-renal AKI ≥ 1

day)

Cardiorenal Sydrome (CRS) Strong relationship between heart

and kidney Heart failure actives the renin-

angiotensin-aldosterone system and vice versa

Kidneys retain salt and water which exacerbates CHF

Cardiorenal Sydrome (CRS)

Cardiorenal Sydrome (CRS) Type 1: acute, primary is acute chf

affective kidney pefusion leading to AKI Type 2: chronic,ongoing chronic cardiac

hypoperfusion leads to effentual ckd Type 3: acute kidney injury causes fluid

retention leading to acute chf exacerbation Type 4: severe ckd/esrd causing ongonig

fluid retention worsening cardiac output

References Pinson, ACP Hospitalist, April, 2015 Kings, “Cor Pulmonale”, Uptodate,

Feb 2014 Kiernan, “Cardiorenal syndrome”,

Uptodate Sept 2015 Pinson, ACP Hospitalist, June 2015