CKD and CHF: The Silent Threat

ASN Renal Week, Official Symposium, October, 2004

Panel Discussion

Panel Discussion

Dr. Donald Silverberg
Dr. Ajay K. Singh
Dr. Anju Nohria
Question index:
Questions received during this symposium have been paraphrased
and the answers submitted by the panelists are presented.


Although your talk was dedicated to nesiritide, but you did spend significant time on diuretics in your talk, and you kept away from aldosterone inhibitor, ARB, and ACE inhibitors, so what would be your thoughts on those drugs?
I wonder if the cardiologist, the last speaker, would comment on the use of digitalis in heart failure.
Is it not true that digitalizing patients with severe congestive heart failure has long been known to increase cardiac output and improve glomerular filtration rate?
I wanted to find out what your experience was with the use of nesiritide in decompensated CHF in patients who have anuric or oliguric CRF.
Could you comment on the use of nesiritide in patients with predominantly right-sided heart failure and also patients with apparent left ventricular failure with preserved ejection fraction?
I was amazed by this heart failure device. Do you think that this will eliminate the role of the nephrologist in providing a replacement therapy? I am just worried that cardiologists do not know how to provide extracorporeal therapy to the degree.
In that study by Butler that you quoted where they looked at the patients who had deterioration of renal function in the hospital with heart failure, they did find the one other factor which was associated with preservation of renal failure - and you did not mention it because you are a cardiologist - was that it was the anemia? There they found that the patients who had the highest hemoglobin were the ones who seemed to maintain their renal function during diuresis when they were hospitalized.

Panelist Responses
(Back to question index)

Although your talk was dedicated to nesiritide, but you did spend significant time on diuretics in your talk, and you kept away from aldosterone inhibitor, ARB, and ACE inhibitors, so what would be your thoughts on those drugs?


Dr. Nohria: : I think those are more long-term drugs that are used for the management of chronic heart failure more for mortality benefits, and they should be used. This is just additional therapy that you might consider using when someone comes into the hospital in a decompensated state. So, I am talking about these agents over and above ACE inhibitors, beta blockers, Aldactone, etc.

(Back to question index) I wonder if the cardiologist, the last speaker, would comment on the use of digitalis in heart failure.

Dr. Nohria: Digitalis has been studied in heart failure patients, and it has not been shown to improve mortality in this patient population. However, it has been shown to reduce recurrent rehospitalizations for congestive heart failure, and now there have been recent data suggesting that achieving target levels of 1 or 1.5 as we used to do is actually harmful in this patient population, and now we aim more for levels in the 0.5 or so range. In fact, we do not even check levels, we just put people on a much lower dose of digitalis than we used to. We usually start out with 0.0625 mg a day or 0.125 mg a day. So, I think it is a weak inotrope that probably gives them some relief in terms of recurrent rehospitalization but clearly does not have a mortality benefit.

(Back to question index)
Is it not true that digitalizing patients with severe congestive heart failure has long been known to increase cardiac output and improve glomerular filtration rate?

Dr. Nohria: I do not know that there is any specific data looking at that, so I am not able to comment on that, but I think it does probably improve cardiac output. I would agree with that.


(Back to question index)
I wanted to find out what your experience was with the use of nesiritide in decompensated CHF in patients who have anuric or oliguric CRF.


Dr. Nohria: I have to say I am currently doing a study myself to look at patients who have GFR less than 50 to begin with and then also come in decompensated, and we are randomizing them to standard therapy versus nesiritide. If I were to base my own experience, I think there are people who have a lot of volume to lose and they diurese like mad regardless of what you give them and then there are others who just do not make any urine unless you give them an inotrope, so I would not be surprised if my own study turns out to be null, but again in the absence of data I cannot tell you. I think the FUSION II study that I mentioned in patients with renal insufficiency and decompensated heart failure would be very informative in exactly that patient population.


(Back to question index)
Could you comment on the use of nesiritide in patients with predominantly right-sided heart failure and also patients with apparent left ventricular failure with preserved ejection fraction?

Dr. Nohria: I will address the second part first. Dr. Burnett's group actually has shown that nesiritide has significant lusitropic effects or myocardial relaxation effects, and this actually may be a very good drug for patients with diastolic dysfunction or normal ejection fraction and congestive heart failure. Empirically, we have been using it with good success in that patient population. With regard to patients who have right-sided heart failure - again, it depends if it is right out of proportion to left with biventricular failure or isolated right-sided heart failure. If it is isolated right-sided heart failure, it may not be the best agent to use because as you know these patients tend to be preload-dependent. If the right-sided heart failure is secondary to pulmonary hypertension and you excessively vasodilate them, you may actually end up dropping their blood pressure to the extent that they actually may have a fatal event. So, in that sense they are not the best agents to treat with a vasodilator, but if they have biventricular failure, right greater than left, and no pulmonary hypertension or not prohibitive amounts of pulmonary hypertension, they would benefit from nesiritide as an adjunct to standard care.

(Back to question index)
I was amazed by this heart failure device. Do you think that this will eliminate the role of the nephrologist in providing a replacement therapy? I am just worried that cardiologists do not know how to provide extracorporeal therapy to the degree.

Dr. Nohria: All I want to say is get in line behind the interventional radiologist. I think dialysis clearly has its place in patients who have significant azotemia. There is a large proportion of patients where it is not just the creatinine that goes up but also the BUN that goes up, and clearly the CHF Solutions device is not going to take care of that problem. So, I think we are only looking to use it in patients who have 10-14 L to lose that takes very long in terms of getting it out with standard therapy, and this might be a nice, efficient way of drying them out quickly mechanically.

(Back to question index)
In that study by Butler that you quoted where they looked at the patients who had deterioration of renal function in the hospital with heart failure, they did find the one other factor which was associated with preservation of renal failure - and you did not mention it because you are a cardiologist - was that it was the anemia? There they found that the patients who had the highest hemoglobin were the ones who seemed to maintain their renal function during diuresis when they were hospitalized.

Dr. Nohria: But then, that is the chicken and egg story, right? Are they anemic because they have renal dysfunction or is renal dysfunction happening because they are anemic?

Dr. Silverberg: I do not know, but I do get these difficult patients, who are just running out of control by increase in fluid. They are not responding, and I just push their hemoglobin up from 12 to 14.



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