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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Congestive heart failure with elevated serum creatinine and blood urea nitrogen (BUN)

GENERAL CONSIDERATIONS

  • Heart failure is common in patients with chronic renal disease, and signs of renal dysfunction (rising serum creatinine) occur in about 10% of patients with heart failure

  • Renal dysfunction with heart failure is directly related to the degree of left ventricular dysfunction and, generally, reduced delivery of cardiac output to the kidney

  • Hemodynamically induced renal dysfunction must be differentiated from chronic renal disease (common), the adverse effects of therapy (eg, angiotensin-converting enzyme [ACE] inhibitors), and diuretic-induced hypovolemia

  • Some heart failure patients present with hepatic and renal dysfunction (hepatorenal syndrome)

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Symptoms of organ hypoperfusion, such as lethargy and mental confusion

PHYSICAL EXAM FINDINGS

  • Evidence of reduced perfusion:

    • – Cool extremities

    • – Low blood pressure

    • – Tachycardia

    • – Diffuse neurologic abnormalities

    • – Jaundice

DIFFERENTIAL DIAGNOSIS

  • Primary renal disease, such as renovascular disease, obstructive uropathy, or urinary tract infection

  • Drug-induced renal dysfunction: nonsteroidal anti-inflammatory drugs, allopurinol, ACE inhibitors

  • Volume depletion from aggressive use of diuretics

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Anemia, abnormal liver function tests, increased prothrombin time

  • Low serum sodium, high potassium

  • Rise in BUN out of proportion to rise in creatinine

ELECTROCARDIOGRAPHY

  • Signs of hyperkalemia or hypocalcemia may be present

  • Nonspecific ST-T–wave changes are common

IMAGING STUDIES

  • Echocardiography usually shows profound left ventricular dysfunction (ejection fraction < 0.20)

  • Echocardiography may show marked left ventricular hypertrophy and diastolic dysfunction, especially in chronic kidney disease patients

DIAGNOSTIC PROCEDURES

  • Right heart catheterization may be useful for defining the hemodynamic abnormality and initiating therapy

TREATMENT

CARDIOLOGY REFERRAL

  • When renal dysfunction occurs during the treatment of heart failure

  • Hypotension or shock

  • When heart failure occurs in a patient with chronic kidney disease

HOSPITALIZATION CRITERIA

  • Rising creatinine and BUN in a patient with heart failure

  • Hypotension, shock

  • Rising potassium levels despite diuretics

  • Low serum sodium and signs of heart failure

MEDICATIONS

  • Stop unnecessary drugs

  • Stop ACE inhibitors if creatinine > 2.75 mg/dL

  • Carefully adjust diuretic dosage

  • Maximize beta-blocker therapy for heart failure

  • Avoid digoxin if possible

THERAPEUTIC PROCEDURES

  • Institute ultrafiltration or hemodialysis if necessary

  • Percutaneous valve or coronary procedures if appropriate

  • Correct anemia if hemoglobin < 10 g/dL

SURGERY

  • Appropriate surgery to improve cardiac function, such as valve repair or coronary bypass

MONITORING

  • ECG monitoring in hospital

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