Chapter 105: The Kidney in Heart Disease
A 65-year-old man with a prior history of type 2 diabetes, congestive heart failure, coronary heart disease, and end-stage chronic kidney disease was seen in the nephrology clinic to discuss starting hemodialysis. The patient refused and decided not to return for the follow-up appointments. A few weeks later, he was brought to the emergency department by his family, who observed that his mental status was “off.” The family denied any recent infections or fevers. Physical examination did not reveal focal neurological deficits, although he had asterixis and a pericardial friction rub. Laboratory investigations showed a significant increase in serum creatinine with academia. Which of the following is the next best step in the management of this patient?
D. Hemodialysis daily for at least 1 week
E. Hemodialysis 3 times per week indefinitely
The answer is D. (Hurst’s The Heart, 14th Edition, Chap. 105) Uremic pericarditis is less responsive to anti-inflammatory therapy with NSAIDs (option A), NSAIDs plus colchicine (option B), or corticosteroids (option C), and should be treated by intensive hemodialysis—that is, daily for at least 1 week (option D). The patient will require long-term dialysis (option E), but this should be performed more often than 3 times per week to treat the uremic pericarditis.
A 66-year-old woman with a prior history of coronary heart disease, arterial hypertension, and type 2 diabetes mellitus presented to the emergency department complaining of a 2-day history of increasing dyspnea, anasarca, and dry cough. Physical examination revealed diffused edema, elevated JVP, ascites, dullness to percussion over the right lung base, and bilateral crackles. Initial blood tests revealed leukocytosis, serum creatinine of 2.9 mg/dL, and metabolic acidosis. ECG showed sinus bradycardia and LVH with strain patterns. An echocardiogram was obtained and revealed a dilated left with a globally depressed ejection fraction of 39%, mild-to-moderate mitral and tricuspid regurgitation, and pulmonary hypertension. The patient also underwent an ultrasound of the abdomen and pelvis, which showed mild ascites with a dilated IVC, and small echogenic kidneys.
The term “cardiorenal syndrome” (CRS) has been coined to describe the entity in which concomitant cardiac and renal dysfunction is present in the same patient. Which of the following types of CRS is this patient most likely to have?