Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content +++ 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 ... Your Access profile is currently affiliated with '[InstitutionA]' and is in the process of switching affiliations to '[InstitutionB]'. Please click ‘Continue’ to continue the affiliation switch, otherwise click ‘Cancel’ to cancel signing in. Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Username Error: Please enter User Name Password Error: Please enter Password Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth