Gadījuma apraksts: Kardiorenāls sindroms.
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Date
2022
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Rīgas Stradiņa universitāte
Rīga Stradiņš University
Rīga Stradiņš University
Abstract
Multimorbiditāte kļūst par pasaulē augošu problēmu. Sirds disfunkcija, akūta vai hroniska, var izraisīt nieru akūtu vai hronisku darbības pasliktināšanos (un otrādi), to sauc par kardiorenālu sindromu (KRS). Lielākā daļa pacientu ar hronisku nieru slimību, piem., mirst no kardiovaskulārām komplikācijām, nevis no pašas nieru slimības. Izprotot kardiorenālā sinroma patofizioloģiskos cēloņus un klīniskās izpausmes, var potenciāli uzlabot pacientu aprūpi un palielināt dzīvildzi.
Gadījuma aprakstā tiek prezentēts 67 gadus vecs vīrietis, kas slimnīcā nonācis ar kardioloģsiska rakstura sūdzībām. Anamnēzē pacientam zināma koronāra sirds slimība (KSS) un sirds mazspēja (NYHA III; kopš 2012.gada) un hroniska nieru slimība (3.stadija KDIGO; kopš 2018.gada), kas atbilst otrā tipa jeb hroniskam kardiorenālam sindromam. Tostarp pacientam ir arī tādas komorbiditātes, kā cukura diabēts, podagrisks artrīts, hipertensija un ātriju fibrilācija, iepriekš bijusi divu stentu implantācija.
Uzņemšanas nodaļā pacientam nosaka diagnozi – miokarda infarkts (MI), sakarā ar klīniku un high-sensitivity sirds troponīna (hs-cTn) līmeņa paaugstināšanos. Asins analīzē pacientam konstatē glomerulārās filtrācijas ātruma samazināšanos (GFĀ; pēc MDRD formulas) un seruma kreatinīna daudzuma pieaugumu, kas liecina par akūtas nieru mazspējas uz hroniskas nieru slimības fona. Pacients tiek stacionēts “Nieru slimību un nieru aizstājterapijas” (NNAT) nodaļā, kur pacientam tiek uzsākta hemodialīze caur centrālo venozo katetru (CVK) un izveidota atriovenozo (AV) fistula, caur kuru plānots veikt regulāru hemodialīzi nākotnē. Paralēli pacientam turpina dinamikā mērīt hs-cTn līmeni, galvenais diagnostiskais izaicinājums ir nošķirt pirmā tipa MI no otrā tipa. Pēc vairāku dienu pacienta novērošanas pacientam tomēr tiek izšķirts par labu perkutānai koronārai intervencei (PKI), kas norit veiksmīgi.
Kopumā KRS iedala piecos tipos pēc gaitas (akūts vai hronisks) un pēc primum movens (sirds vai nieres). Autors uzskata, ka šajā gadījuma otrā tipa KRS pārgājis pirmā tipa KRS, ar akūtu nieru dekompensāciju akūtas sirds dekompensācijas dēļ. Tomēr slimības primum movens noteikt ir grūti, un teorētiksi atgriezeniskā cēloņsakarība arī ir iespējama, t.i., ka šis gadījums atbilst trešā tipa renokardiālam sindromam, kur nieru dekompensācija (uz medikamentu, hipertensjas, hiperurikēmijas bāzes) izraisījusi MI attīstību.
Diemžēl hospitalizācijas laikā pacientam netika veikta ehokardiogrāfija, kā arī netika izmērīti bioloģiskie marķieri (piem., B-tipa nātrijurētiskā peptīda [BNP]), kas varētu līdzēt prognozes veidošanā. Aprūpē pacientam netika nozīmēti antikoagulanti, un, zinot, ka 2021.gada decembrī pacients nonācis slimnīcā ar isēmisku insultu, var spekulēt, ka tas bija viens no faktoriem. Kopumā pacienta prognoze pessima.
Multimorbidity is becoming a growing problem worldwide. Cardiac dysfunction, acute or chronic, can lead to acute or chronic renal impairment (and vice versa), called cardiorenal syndrome (CRS). Most patients with chronic kidney disease, for example, die from cardiovascular complications rather than from the kidney disease itself. Understanding the pathophysiological causes and clinical manifestations of cardiorenal syndrome has the potential to improve patient care and increase survival. This case report presents a 67-year-old man admitted to hospital with cardiac complaints. The patient has a known history of heart failure (NYHA III; since 2012) and chronic kidney disease (KDIGO stage 3; since 2018), consistent with type 2 or chronic cardiorenal syndrome. The patient also has comorbidities such as diabetes mellitus, gouty arthritis, hypertension and atrial fibrillation, and has had two previous stent implantations. On admission, the patient is diagnosed with myocardial infarction (MI), due to the clinicopathological presentation and elevation of high-sensitivity cardiac troponin (hs-cTn). On blood analysis, the patient shows a decrease in glomerular filtration rate (GFR; MDRD formula) and an increase in serum creatinine, suggesting the development of acute renal failure on the background of chronic kidney disease. The patient is admitted to the Renal Disease and Replacement Therapy (RDRT) unit, where hemodialysis is started via a central venous catheter (CVC) and an arteriovenous (AV) fistula is created, through which regular hemodialysis is planned in the future. In the meantime, dynamic measurements of hs-cTn levels are being made, the main diagnostic challenge being differentiation between type 1 from type 2 MI. However, after several days of follow-up of the patient, it is decided in favor of percutaneous coronary intervention (PCI), which is successful. In general, CRS is divided into five types according to the course (acute or chronic) and the primum movens (cardiac or renal). The author considers that in this case, type 2 CRS evolved into type 1 CRS, with acute renal decompensation due to acute cardiac decompensation. However, it is difficult to determine the primum movens of the disease, and theoretically reverse causation is also possible, i.e. that this case corresponds to type 3 renocardial syndrome, where renal decompensation (due to medication use, hypertension and hyperuricaemia) led to the development of MI. Unfortunately, the patient did not undergo echocardiography during hospitalisation, nor were biomarkers (e.g. B-type natriuretic peptide [BNP]) measured that could contribute to prognosis. The patient was not prescribed anticoagulants during care, and knowing that the patient was admitted to hospital with ischaemic stroke in December 2021, one can speculate that this was a factor. Overall, the patient's prognosis is pessimistic.
Multimorbidity is becoming a growing problem worldwide. Cardiac dysfunction, acute or chronic, can lead to acute or chronic renal impairment (and vice versa), called cardiorenal syndrome (CRS). Most patients with chronic kidney disease, for example, die from cardiovascular complications rather than from the kidney disease itself. Understanding the pathophysiological causes and clinical manifestations of cardiorenal syndrome has the potential to improve patient care and increase survival. This case report presents a 67-year-old man admitted to hospital with cardiac complaints. The patient has a known history of heart failure (NYHA III; since 2012) and chronic kidney disease (KDIGO stage 3; since 2018), consistent with type 2 or chronic cardiorenal syndrome. The patient also has comorbidities such as diabetes mellitus, gouty arthritis, hypertension and atrial fibrillation, and has had two previous stent implantations. On admission, the patient is diagnosed with myocardial infarction (MI), due to the clinicopathological presentation and elevation of high-sensitivity cardiac troponin (hs-cTn). On blood analysis, the patient shows a decrease in glomerular filtration rate (GFR; MDRD formula) and an increase in serum creatinine, suggesting the development of acute renal failure on the background of chronic kidney disease. The patient is admitted to the Renal Disease and Replacement Therapy (RDRT) unit, where hemodialysis is started via a central venous catheter (CVC) and an arteriovenous (AV) fistula is created, through which regular hemodialysis is planned in the future. In the meantime, dynamic measurements of hs-cTn levels are being made, the main diagnostic challenge being differentiation between type 1 from type 2 MI. However, after several days of follow-up of the patient, it is decided in favor of percutaneous coronary intervention (PCI), which is successful. In general, CRS is divided into five types according to the course (acute or chronic) and the primum movens (cardiac or renal). The author considers that in this case, type 2 CRS evolved into type 1 CRS, with acute renal decompensation due to acute cardiac decompensation. However, it is difficult to determine the primum movens of the disease, and theoretically reverse causation is also possible, i.e. that this case corresponds to type 3 renocardial syndrome, where renal decompensation (due to medication use, hypertension and hyperuricaemia) led to the development of MI. Unfortunately, the patient did not undergo echocardiography during hospitalisation, nor were biomarkers (e.g. B-type natriuretic peptide [BNP]) measured that could contribute to prognosis. The patient was not prescribed anticoagulants during care, and knowing that the patient was admitted to hospital with ischaemic stroke in December 2021, one can speculate that this was a factor. Overall, the patient's prognosis is pessimistic.
Description
Medicīna
Medicine
Veselības aprūpe
Health Care
Medicine
Veselības aprūpe
Health Care
Keywords
kardiorenāls sindroms, koronāra sirds slimība, sirds mazspēja, hroniska nieru slimība, miokarda infarkts, high-sensitivity sirds troponīns, glomerulārās filtrācijas ātrums, dialīze, hemodialīze, B-tipa nātrijurētisks peptīds, cardiorenal syndrome, coronary heart disease, heart failure, chronic kidney disease, myocardial infarction, high-sensitivity cardiac troponin, glomerular filtration rate, dialysis, hemodialysis, B-type natriuretic peptide