cv- nephro combined conference 2012.06.06
DESCRIPTION
CV- nephro combined conference 2012.06.06. 報告者: fellow 1 陳筱惠 指導醫師:陳冠興醫師 Commented by CV1 張其任醫師. Patient Profile. Name: 張 O 嗣 Sex: female Age: 90-year-old Chart number: 487733 Date of admission: 2011/11/18. Chief Complaint. Persistent dizziness for 1 day. Present Illness. - PowerPoint PPT PresentationTRANSCRIPT
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報告者: fellow 1 陳筱惠
指導醫師:陳冠興醫師Commented by CV1 張其任醫師
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Name: 張 O 嗣 Sex: female Age: 90-year-old Chart number: 487733 Date of admission: 2011/11/18
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Persistent dizziness for 1 day
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Underlying diseases: chronic kidney disease (stage 4), congestive heart failure, and atrial fibrillation
Dizziness with bradycardia episode at home (HR around 40bpm)
Associated S/S: no palpitation, chest pain, cold sweating, or consciousness disturbance
At ER: clear consiousness, af SVR
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Hypertension (BP when OPD follow-up: 180~/70~mmHg)
Heart failure, LVEF:68%, HCVD related, atrial fibrillation rhythm
Chronic kidney disease, stage 4, eGFR: 29.4ml/min, 2011/04/24 crea: 1.64mg/dl
Obstrutive sleep apnea syndrome with restrictive lung
Asthma history Other significant systemic diseases:
denied
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Doxazosin 4mg 1# bid Isosorbide-5-mononitrate cr 60mg 1# qd Furosemide 40ng 0.5# qd Aliskiren 150mg 1# qd 2011/06/28~ Exforge (Amlodipine 5mg + Valsartan
80mg) 1# bid 2011/11/15~◦ Micardis Plus (Telmisartan 40mg + HCTZ 12.5mg)
1# qd 2011/10/18~2011/11/15◦ Telmisartan 40mg
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Allergy: no known allergy Alcohol: denied; betel-nut: denied;
cigarette: denied Over-the-counter medication or chinese
herb: nil
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No family history of malignancy, bleeding diathesis, heart, liver, kidney, or hereditary diseases
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Vital signs: blood pressure: 135/58mmHg; temperature: 36.5‘C; pulse rate: 44/min; respiratory rate: 18/min
General appearance: acute ill looking Eye: conjunctiva: pale, sclera: no icteric Neck: supple, no lymphadenopathy or jugular vein
engorgement Chest: symmetric expansion
breathing sound: bilateral clear heart sound: irregular heart beats, no S3 or S4, no
murmurs Abdomen: soft, flat, no tenderness, muscle guarding, or rebounding liver/spleen: impalpable bowel sound: normoactive Extremities: no lower limb pitting edema Skin: intact, no rash
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WBC 6.2x1000/ul
Hgb 8.3 g/dl
Hct 25.4 %
MCV 87 fL
PLT 159 x1000/uL
Segment 78.9 %
BUN 118.1 mg/dL
Creatinine 4.43 mg/dl
GPT 9 IU/L
Na 134 mEq/L
K 8.2 mEq/L
Ca 8.2 mg/dL
Mg 2.3 mEq/L
Tropo - I <0.01 ng/mL
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Atrial fibrillation with slow ventricular rate, suspect hyperkalemia induced
Acute on chronic kidney disease, favor ARB drug effect, complicated with hyperkalemia and azotemia
Hypertension, poorly controlled Heart failure, LVEF:68%, HCVD related, atrial
fibrillation rhythm Obstrutive sleep apnea syndrome with
restrictive lung Asthma history
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H/D
U/O 2020 660 740 860
BW 55.46 54.8 55.9 56.6
BUN 118.1 58.8
Crea 4.43 2.65
Na 134 138
K 8.5 5.1
Ca
P
C02 21.3
189/88mmHg
141/72mmHg
149/70mmHg
165/79mmHg
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U/O 230 1630 2450 350 920
BW 69.5 59.1 58.3
BUN 68.7 73
Crea 2.82 2.45
Na 125 123
K 4.7 5.0
Ca 8.3 8.0
P 4.8 4.5
C02
190/99mmHg
159/72mmHg
186/84mmHg
206/94mmHg
186/89mmHg
Kidney echo
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U/O 900 820 400 810 710
BW 57.9 57.2 59.5 60.7
BUN 51 51.4
Crea 1.87 2.63
Na 127 123
K 4.5 4.2
Ca 8.2 7.7
P 2.7 3.0
C02
201/96mmHg
181/80mmHg
145/66mmHg
179/86mmHg
156/72mmHg
Cortisol 14.1Renin 1644Aldosterone 328TSH 0.77Free T4 26.939
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U/O 400 1210 700 300 400
BW 61.6 61.1 61.3 62.4
BUN 58.7 63.3 72.8
Crea 2.59 2.31 3.12
Na 123 125 126
K 4.9 5.3 5.6
Ca 8.0 8.0
P 4.7 5.5
C02 15.4 17.3
194/87mmHg
172/79mmHg
172/69mmHg
151/70mmHg
209/86mmHg
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U/O 1320 2500 600 300 950
BW 61.6 60 62 62 63.1
BUN 80.4
Crea 2.65
Na 128
K 4.8
Ca 8.2
P 6.0
C02 21.1
179/82mmHg
156/76mmHg
174/84mmHg
169/82mmHg
176/75mmHg
Renin 995
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U/O 2180 1400 650 200 600
BW 61.8
BUN 80.7 47
Crea 3.01 2.08
Na 123 130
K 3.9 3.8
Ca 7.9 8.7
P 5.1 2.7
C02
188/84mmHg
193/85mmHg
192/78mmHg
201/95mmHg
210/85mmHg
H/D
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U/O 450 700 300 130 90
BW 58.2
BUN 58.1
Crea 3.12
Na 127
K 4.1
Ca 8.4
P 4.3
C02 22.5
203/90mmHg
191/83mmHg
204/90mmHg
174/75mmHg
172/95mmHg
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U/O 100 80 150 230 0
BW 58.7
BUN 47.3
Crea 4.78
Na 127
K 4.9
Ca 7.9
P 3.6
C02 24.9
177/81mmHg
178/96mmHg
196/89mmHg
179/88mmHg
202/89mmHg
Hickman implantation
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U/O 0 750 650 500 600
BW 54.9
BUN 37.5
Crea 4.83
Na 134
K 4.3
Ca 8.0
P 4.6
C02 23.7
168/74mmHg
164/87mmHg
163/69mmHg
141/74mmHg
168/76mmHg
Renal angiography
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U/O 1100 1100 2250 1300 950
BW
BUN 37.9 44.5
Crea 4.92 4.57
Na 131 131
K 4.4 4.5
Ca 7.8 8.5
P 4.9 5.4
C02 23.4 22.6
197/85mmHg
151/69mmHg
168/79mmHg
122/61mmHg
161/74mmHg
Hold H/D
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U/O 1450 1400
BW 50.2
BUN 36.5 19.6
Crea 2.83 1.74
Na 133 136
K 4.4 5.0
Ca 9.0 8.6
P 4.2 4.0
C02
147/81mmHg
134/64mmHg
119/54mmHg
1/17 remove hickman
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Renal Artery Stenosis: Optimizing Diagnosis and TreatmentProgress in Cardiovascular Diseases 54 (2011) 29–35
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1st: atherosclerotic lesions, 90% of all renovascular lesions◦ Typically in older individuals◦ An equal prevalence in men and women◦ Predominantly at or near the origin of the renal
artery and usually are associated with aortic disease
◦ May present with hypertension or renal insufficiency
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2nd: fibromuscular dysplasia (FMD)◦ More often in young women◦ Usually associated with hypertension without
renal insufficiency
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A limited literature addresses the clinical factors that are predictive of finding atherosclerotic RAS and that may be useful in guiding appropriate screening.
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Doppler ultrasound Computed tomography angiography (CTA)
and magnetic resonance angiography (MRA) Conventional angiography
Imaging For Renovascular DiseaseSeminars in Nephrology, Vol 31, No 3, May 2011, pp 272-282
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Duplex ultrasonography: screening test◦ Sensitivity: 92.5% to 98%; specificity: 96% to 98%◦ Nontoxic◦ No exposure to ionizing radiation◦ Capable and reliable◦ Major limitation: dependence on technician skill
for acquisition of adequate images; others: obesity, bowel gas, and recent food intake
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Computed tomography angiography (CTA):◦ Sensitivity and specificity: > 95%◦ Multicenter Renal Artery Diagnostic Imaging
Study in Hypertension (RADISH) study SEN 64%, SPE 93%
◦ Qualitative◦ Risk of contrast nephropathy
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Magnetic resonance angiography (MRA):◦ Slightly lower sensitivities and specificities than
CTA; RADISH study SEN 62%, SPE 84%◦ To measure flow, renal perfusion, and renal
function◦ Poorer spatial resolution, limited availability,
patient tolerance, and the need for extended breath-holding
◦ Nephrogenic sclerosing fibrosis associated with Gadolinium in patients with renal insufficiency
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Duplex ultrasonography is inferior to MRA and CTA.
Diagnostic tests for renal artery stenosis in patients suspected of having renovascular hypertension: a meta-analysis. Ann Intern Med 2001;135:401-411.
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Captopril renography:◦ Poor screening test
Dependent on comparative imaging of the right and left kidneys
The incidence of bilateral RAS is approximately 30%.◦ May be useful when trying to determine the
physiologic significance of a known intermediate stenosis
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Invasive angiography: gold standard◦ Confirm the diagnosis based on prior noninvasive
testing and with the intent to perform an intervention
◦ The most commonly used methodology: intra-arterial digital subtraction angiography
◦ Complications: related to the vascular access, placement of the guidecatheter into the renal artery, balloon and stent deployment, and contrast administration
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◦ Carbon dioxide (CO2) Image quality is reduced. May create greater uncertainty about lesion severity
unless combined with judicious use of iodinated contrast
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Medical therapy Revascularization: balloon angioplasty +-
stenting or Surgical bypass or reconstruction
Goals:◦ Blood pressure control◦ Treatment of heart failure and/or pulmonary edema◦ Prevention of nephropathy
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Medical therapy Lifestyle interventions:
◦ Dietary recommendations in atherosclerotic RAS: Increased intake of fruits and vegetables, dietary
calcium through low fat dairy products
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Angiotensin-converting enzyme (ACE) inhibitors◦ Potential to induce acute hemodynamically
mediated renal failure in patients with RAS◦ Lower cardiovascular event rates (10% vs 13%)
and need for dialysis (1.5% vs 2.5%)◦ The cost of an increased risk of hospitalization for
acute renal failure (1.2 vs 0.6%) Selection bias: patients with better renal function
and/or less severe disease are treated with these agents resulting in an apparent improvement of outcome
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Other agents used to control the atherosclerotic process are important for the care of patients with atherosclerotic RAS.◦ Statins: decrease death, limit lesion progression,
and promote restenosis-free survival◦ Platelet inhibitors: prevention of future
cardiovascular events
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Revascularization:◦ Balloon angioplasty +- stenting:
Lesion severity, renal function, the skill level of the operators, and complication rates
◦ Surgical bypass or reconstruction: Not benefit over angioplasty High rates of adverse outcomes with surgery,
including perioperative mortality of approximately 10%
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When stenting is performed, there are a number of technical factors that should be considered as part of the procedure.◦ “No touch” technique for engaging a catheter into
the renal artery reduce the risk of atheroembolism
◦ No embolic protection device is approved by the Food and Drug Administration for use in the renal artery.
◦ Abciximab (a platelet glycoprotein IIbIIIa inhibitor) ??
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A “cure” of hypertension with revascularization◦ < 10% in patients with atherosclerotic RAS◦ Approximately 50% in patients with FMD
Younger patients more likely to achieve this outcome.
Consistent and sustained blood pressure–lowering effect of revascularization
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Considerable controversy exists regarding the use of revascularization of atherosclerotic RAS to treat or prevent the development of ischemic nephropathy.◦ Stent revascularization in patients with ischemic
nephropathy and significant stenoses resulted in a slower rate of progression of nephropathy.
◦ In a minority of patients, an actual improvement in renal function is seen with either stenting or surgical revascularization.
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FMD: balloon angioplasty◦ In a minority of FMD cases, there will be
concomitant aneurysms of the renal artery. Atherosclerotic RAS
◦ Stenting has proven superior to balloon angioplasty.
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Left kidney: 9.9 cm
Right kidney: 7.7 cm
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Right renal artery: occluded Left renal artery: proximal 71% stenosis
◦ Balloon dilatation procedures: 56% residual stenosis
◦ Stenting: 5% residual stenosis