Thanks Elan for presenting a case of a 63yo M with HIV HFrEF (25%), EtOH cirrhosis (CP Class A, MELD 8), HTN, HLD, and ongoing alcohol use with dietary nonadherence presenting with shortness of breath and anasarca. His JVD was elevated on presentation, and CT PE/AP in the ED revealed dilated IVC and e/o pulmonary edema.
He underwent diuresis and initially improved, but 48 hours into his hospitalization, he developed oliguric AKI, hepatic encephalopathy, and relative hypotension.
Urine studies were consistent with activation of RAAS and ADH (kidneys seeing low perfusion, and echo was concerning for biventricular failure with EF < 20%. A trial of Lasix managed to produce a UOP of 800cc in 24 hours, so a decision was made to transfer pt to the Stepdown for dobutamine assisted diuresis for suspected Cardiorenal Syndrome. Pt ultimately diuresed 18L of fluid (his weight also went down 10+kg, that’s around 22lbs!) and his renal function quickly returned to baseline after aggressive diuresis.
The diagnosis dilemma for this case was the etiology of pt’s AKI. He was exposed to contrast, hence 48 hours later contract-induced nephropathy can be expected. He also has liver cirrhosis with acute decompensation, hence hepatorenal syndrome (HRS) is something that we cannot miss. Given his poor cardiac function, cardiorenal syndrome (CRS) is also high on the differential!
Keep in mind that there are 5 types of Cardiorenal Syndrome:
- Type 1: Acute heart failure -> AKI, decreased renal arterial flow due to acutely decompensated HF
- Type 2: Chronic HF leading to chronic renal hypoperfusion leading to CKD
- Type 3: AKI leading to adverse cardiac events
- Type 4: CKD leading to adverse cardiac events
- Type 5: Multifactorial, systemic insult leads to both cardiac and renal failure
Regardless, the general principle is to restore renal perfusion. Given his biventricular failure, volume status, and initial presentation, Cardiorenal is suspected as more likely, hence pt received inotropic support (improves forward flow) and diuresis (Get pt back on the right side of the Frank Starling curve, also improves forward flow). Overall management of CRS is not much different compared to acute decompensated heart failure.
There is some evidence that more aggressive diuresis is associated with better outcomes (ESCAPE trial).