Cagliari 30 aprile � 3 maggio 2011 LV dysfunction and pulmunary congestion in dialysis patients F. Mallamaci
Death rate (1 year) Death rate (1 year) % % % % 100 100 100 100 ESRD ESRD SIN registry SIN registry X 5 10 10 10 10 1 1 1 1 X 350 ISTAT ISTAT 0.1 0.1 0.1 0.1 0.01 0.01 0.01 0.01 <15 15- -24 25 24 25- -44 45 44 45- -64 65 64 65- -74 >74 74 >74 <15 15 Age (years) Age (years) Courtesy of Massimo Cirillo 2006 Courtesy of Massimo Cirillo 2006
in ESRD ESRD Cardiac disease in Cardiac disease 70% LVH 70% LVH ∼ 40% LV systolic dysfunction: ∼ LV systolic dysfunction: 40% ∼ 100% LV diastolic dysfunction: ∼ LV diastolic dysfunction: 100% Why the risk of cardiac disease is so high in Why the risk of cardiac disease is so high in ESRD? ESRD? How this risk is generated? How this risk is generated?
Go AS, New Engl J Med. 351: 1296; 2004 Go AS, New Engl J Med. 351: 1296; 2004 1.120.295 individuals, follow up 2.8 years 1.120.295 individuals, follow up 2.8 years risk factors peculiar to CKD risk factors peculiar to CKD Relative Risk (fully independent) (fully independent) Anemia Anemia Relative Risk ⇑ P ⇑ P ⇑ ⇑ PTH PTH 4 4 Volume expansion Volume expansion 3.4 3.4 3 3 Old age Old age 2.8 2.8 2 2 2.0 2.0 Emerging risk factors 1.4 Inflammation Inflammation 1.0 1.0 1 1 ⇑ Sympathetic activity ⇑ Sympathetic activity ⇑ Cholesterol ⇑ ⇑ ⇑ Asymmetric Dimethyl Arginine (ADMA) Cholesterol Asymmetric Dimethyl Arginine (ADMA) REFERENCE REFERENCE REFERENCE ⇑ Glucose/Diabetes ⇑ Glucose/Diabetes 0 0 The GFR captures the The GFR captures the prognostic value of these prognostic value of these Why volume expansion is so Why volume expansion is so non- -Framingham risk Framingham risk non difficult to control in the difficult to control in the GFR GFR modern dialysis era when UF modern dialysis era when UF factors factors Simple measurements of TBW or ECV Simple measurements of TBW or ECV technology allows precise and technology allows precise and ml/min ml/min effective effective volume volume removal removal insufficient or even misleading in HD pts insufficient or even misleading in HD pts 120 120 profiling? profiling? 60< 60< 60 60 30 45 30 45 15 15 REFERENCE REFERENCE 0 0 0 0 3bCKD 3bCKD 3aCKD 3aCKD 5CKD 5CKD 4CKD 4CKD
In reality fluids volume is � � In reality fluids volume is Cardiac Extracellular Fluids Cardiac Extracellular Fluids function Volume function Volume Extracellular Volume (sodium space) Extracellular Volume (sodium space) ∼ ∼ 16 16- -18 L 18 L Blood Volume ( (~30% extracellular volume) ~30% extracellular volume) Blood Volume LV filling Pressure LV filling Pressure 5.6L 5.6 L 8- -10 mmHg 10 mmHg 8 located in the vascular space , encompassing located in the vascular space , encompassing heart, aorta down to capillary bed and back to heart, aorta down to capillary bed and back to the venous system � � . the venous system . � variable space, depending on vascular tone � variable space, depending on vascular tone and compliance and compliance The fundamental parameter for defining the loading conditions of The fundamental parameter for defining the loading conditions of the CV system, i.e. the relationship between circulating volume and and the CV system, i.e. the relationship between circulating volume CV function. CV function.
However highly reliable, However highly reliable, this this is is an an invasive invasive technique and therefore it technique and therefore it is employed in the acute is employed in the acute setting only. setting only. Capillary Wedge Pressure Capillary Wedge Pressure a very reliable indicator of a very reliable indicator of LV filling pressure LV filling pressure Atrial Pressure Atrial Pressure Capillary Pressure at Capillary Pressure at LV Diastolic (filling) LV Diastolic (filling) alveolar level alveolar level Pressure Pressure which depends on 2 components: which depends on 2 components: 1) volume 2) LV function component . 1) volume 2) LV function component . Therefore it reflects the loading conditions of the Therefore it reflects the loading conditions of the LV at a given Blood Volume LV at a given Blood Volume � .. Is there any reliable � .. Is there any reliable proxy of LV filling pressure ? proxy of LV filling pressure ?
CHEST CHEST 127:1690, 2005 127:1690, 2005 Pulmonary edema Pulmonary edema Pulmonary Water Pulmonary Water Capillary Pressure at Capillary Pressure at alveolar level alveolar level Lung comets Lung comets Lung water ! the number of lung comets is strictly ! the number of lung comets is strictly proportional to lung water proportional to lung water
Detection of pulmonary congestion by chest ultrasound (US) in dialysis patients. Mallamaci F, Benedetto A, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C 3;586; 2010 Useful in Dialysis patients? Useful in Dialysis patients? an inclusive study: All but 3 patients of a large dialysis unit (n=78). (n=78). an inclusive study: All but 3 patients of a large dialysis unit Lung comets, BIA, echocardiography measured pre and post Lung comets, BIA, echocardiography measured pre and post- -dialysis dialysis Predialysis Predialysis Median # of Median # of comets: 18 comets: 18 Prevalence Prevalence Lung Comets Lung Comets (%) (%) (n) (n) 50 50 Moderate lung Moderate lung Severe lung Severe lung The lack of association with hydration The lack of association with hydration congestion congestion congestion congestion status indicates that in this population LV status indicates that in this population LV dysfunction is the fundamental driver of dysfunction is the fundamental driver of 40 60 40 60 lung congestion in ESRD. lung congestion in ESRD. 35% 35% 50 50 30 30 28% 28% 40 40 20 20 30 30 20 20 20 20 17 17 10 10 15 15 10 10 0 0 0 0 <14 14- -30 >30 30 >30 Hypo Normal Hyper <14 14 Hypo Normal Hyper Lung Comets number Lung Comets number Hydration Status by BIA Hydration Status by BIA
Detection of pulmonary congestion by chest ultrasound (US) in dialysis patients. Mallamaci F, Benedetto A, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C 3:586 ; 2010 Left atrial Volume Left atrial Volume r=0.39, P<0.001 30 70 r=0.33, P=0.002 (mL/m 2.7 ) Pulmonary Pressure Pulmonary Pressure 25 (mmHg) (mmHg) 60 20 50 40 15 30 10 20 5 10 0 0 0 50 100 150 200 0 50 100 150 200 Lung comets (n) Lung comets (n) 80 r=-0.73, P<0.001 70 60 LV Ejection LV Ejection Fraction (%) Fraction (%) 50 40 30 20 10 0 50 100 150 200 Lung comets (n)
Detection of pulmonary congestion by chest ultrasound (US) in dialysis patients. Mallamaci F, Benedetto A, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C 3:586; 2010 Median # of Median # of Postdialysis Postdialysis comets: 10 comets: 10 Prevalence Prevalence (%) (%) 50 50 Moderate lung Moderate lung Severe lung Severe lung congestion congestion congestion congestion 40 40 33% 33% 30% 30% 30 30 20 20 10 10 0 0 <14 14- -30 >30 30 >30 <14 14 Lung Comets number Lung Comets number
Detection of pulmonary congestion by chest ultrasound (US) in dialysis patients. Mallamaci F, Benedetto A, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C 3:586 ; 2010 Left atrial Volume Left atrial Volume 30 r=0.30, P=0.01 70 (mL/m 2.7 ) Pulmonary Pressure Pulmonary Pressure r=0.32, P=0.006 25 (mmHg) (mmHg) 60 20 50 40 15 30 10 20 5 10 0 0 0 50 100 150 200 0 50 100 150 200 Lung comets (n) Lung comets (n) 80 r=-0.64, P<0.001 70 60 LV Ejection LV Ejection Fraction (%) Fraction (%) 50 40 30 20 10 0 50 100 150 200 Lung comets (n)
Detection of pulmonary congestion by chest ultrasound (US) in dialysis patients. Mallamaci F, Benedetto A, Tripepi R, Rastelli S, Castellino P, Tripepi G, Picano E, Zoccali C 3:586; 2010 140 r=0.75 P<0.001 120 100 80 Lung comets changes (n) 60 40 20 0 -20 0 20 40 60 80 100 120 140 160 180 200 Pre-dialysis lung comets (n) Lung comets changes are directly associate to the number of Lung comets changes are directly associate to the number of comets before the dialysis session � � .. comets before the dialysis session ..
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