Cardiorenal syndrome is a complex condition associated with significant morbidity in the form of symptoms secondary to fluid overload, leading to hospitalisations, and portends increased mortality. Both the diagnosis and management of the conditions are complicated by the fact that there is dysfunction of the heart as well as the kidney, usually with uncertainty with regards to the timing of the first insult. Management in primary care, or in the emergency setting, tends to be predominantly focused on short-term improvement in function of one organ, leading to deleterious effects on the other. A consensus multi-disciplinary approach involving both cardiologists and nephrologists has been advocated in order to devise a unified management plan. Our report presents findings of monthly cardio-nephrology multi-disciplinary team meetings and illustrates that this can be an efficacious approach both in terms of avoiding unnecessary outpatient clinic visits, as well as consensus decision-making.
Introduction
Cardiorenal syndromes (CRS) are defined as a spectrum of disorders affecting the heart and kidney, in which acute or chronic dysfunction of one organ leads to acute or chronic dysfunction of the other.1,2 Management of this condition can be challenging as it portends significant morbidity due to symptom burden, as well as recurrent hospitalisations and increased mortality.1-3 In addition, as there is a relative paucity of evidence-based therapy, management strategies for CRS have been largely empirical and goal-directed towards improvement of function of one organ, frequently at the cost of the other. For instance, acute kidney injury in heart failure frequently leads to stoppage of prognostic heart failure treatment such as renin–angiotensin–aldosterone system inhibitors (RAASi), leading to short-term improvement in renal function, but this is offset by increased heart failure hospitalisations and mortality.4 A cardio-nephrology multi-disciplinary team (MDT) approach has been recommended for the effective management of patients with CRS.1,5
Method
Our cardio-nephrology MDT consists of consultant cardiologists with a specialist interest in heart failure (HF), consultant nephrologists, advanced nurse practitioners (HF and nephrology) and HF specialist nurses. MDT meetings are conducted on a monthly basis and typically last 60 to 90 minutes (replacing the departmental educational meeting). Suggestions made as consensus from the MDT discussion, are conveyed through a letter to the referrers. We studied the outcomes generated from MDT discussions for patients with HF and CRS discussed at the monthly cardiorenal MDT from October 2017 to March 2019.
Results
There were 73 patients discussed at the cardio-nephrology MDT meeting during the 18-month period studied. Sources of referrals included primary care (community HF nurses and general practitioners) 19%, nephrologists (22%), ambulatory HF unit (AHFU) 21% (AHFU is a HF specialist nurse-delivered HF management unit that treats patients with acutely decompensated HF on an outpatient basis), cardiology outpatient clinic (OPC) 20%, cardiology ward 15%, and other departments from the hospital 3% (elderly care, diabetologists). During the first six months, we received an average of two referrals per meeting. However, as awareness of the meeting spread among hospital colleagues and primary care, the number of referrals per meeting increased to an average of five per MDT meeting during the subsequent 12 months. Referrers to the MDT raised a variety of queries, such as need for advanced HF therapies, e.g. devices/cardiac transplant, suitability for renal replacement therapy, need for renal biopsy or need for palliative care discussions. The majority of patients referred (39/73, 53%) had HF with preserved ejection fraction (HFpEF), 25/73 patients (34%) had HF with reduced ejection fraction (HFrEF) and 9/73 patients (13%) had HF with mid-range ejection fraction (HFmrEF). Most patients (46/73, 63%) had chronic kidney disease (CKD) stage 4, 14/73 (19%) CKD stage 5 and 13/73 (18%) CKD stage 3, with 10% having sustained recent acute kidney injury (AKI) on CKD. CRS subtypes were classified at the MDT based on the Acute Dialysis Quality Initiative.2 The majority of patients referred to the MDT had CRS type 2 (62%), whereas CRS type 4 was diagnosed in 24%, CRS type 3 in 11% and CRS type 1 in 3% of referrals.
Outcomes of joint cardio-nephrology MDT decisions were analysed based on consensus recommendations made to the referring team, the actual plan followed and avoidance of a further outpatient clinic attendance based on the MDT consensus. Table 1 outlines the recommendations made by the cardio-nephrology MDT meeting and the final outcomes. Recommendations from the MDT meeting were followed by the parent team in more than 90% of cases. Based on the MDT recommendation, 48% of patients did not need a further outpatient clinic appointment (renal or cardiac) as the query raised by the parent team was addressed satisfactorily and communicated to the parent team. Additional benefits of a dedicated joint cardio-nephrology MDT include accurate diagnosis of true AKI, differentiating this from fluctuations in serum creatinine due to treatment with diuretics in acute decompensated HF. This is also important in consensus decision-making of continuing prognostic medications in HFrEF, such as RAASi therapy. Other recommendations included advanced HF therapies, such as device therapy or cardiac transplant, suitability for renal replacement therapy or the need for advanced care planning palliative discussions.
Discussion
Analysis of outcomes from our cardio-nephrology MDT meetings, has illustrated that this can be an efficacious approach in the management of patients with CRS. These patients frequently present via the emergency department or the acute physician with symptoms or signs of either cardiac or renal dysfunction dominating, leading to management decisions focusing on one organ alone. This can lead to deleterious effects on the other organ, thereby setting off a vicious cycle. A classic example of this is the cessation of lifesaving RAASi therapy in patients with HFrEF when diuretic therapy leads to transient perturbations in serum creatinine. This in turn leads to adverse cardiac outcomes, such as worsening HF symptoms and mortality.4 The cardiorenal MDT can provide a consensus and evidence-based expert opinion regarding management of this complex condition. A further secondary-care clinic visit was deemed unnecessary and obviated in nearly half the cases, based on consensus advice from the MDT meeting. Importantly, this reduced the inconvenience to HF patients who already have multiple clinical appointments due to their comorbidities. In addition, a reduction in outpatient clinic appointments through secondary-care referrals, is likely to have led to cost savings and ensured that these outpatient clinic slots were released for other suitable patients.
Conclusion
MDT working with a collaborative approach has several potential benefits, including improved care outcomes through use of evidence-based practice, better utilisation of healthcare resources through streamlining of care, and increased satisfaction for team members. A consensus collaborative approach is particularly relevant for patients with a long-term condition, such as CRS, whereby a unified management plan is conveyed to the patient, primary care and community teams, leading to streamlined care. Our report has illustrated that joint cardio-nephrology MDT meetings can be beneficial for both CRS patients and healthcare systems.
Key messages
- Cardiorenal syndrome is a complex condition, which is associated with significant morbidity and mortality
- Management of cardiorenal syndrome requires a collaborative approach between cardiology and nephrology multi-disciplinary teams
- As demonstrated by our data, joint multi-disciplinary cardio-nephrology team meetings can be beneficial for both cardiorenal syndrome patients and healthcare systems
Conflicts of interest
None declared.
Acknowledgements
Aintree Ambulatory Heart Failure Unit, Department of Nephrology, Aintree University Hospital.
Funding
None relevant.
Editors’ note
See also the editorial by Pickup et al.
References
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2. Ronco C, McCullough PA, Anker SD et al. Cardiorenal syndromes: an executive summary from the consensus conference of the Acute Dialysis Quality Initiative (ADQI). Contrib Nephrol 2010;165:54–67. https://doi.org/10.1159/000313745
3. Heywood JT. The cardiorenal syndrome: lessons from the ADHERE database and treatment options. Heart Fail Rev 2004;9:195–201. https://doi.org/10.1007/s10741-005-6129-4
4. Clark AL, Kalra PR, Petrie MC, Mark PB, Tomlinson LA, Tomson CR. Change in renal function associated with drug treatment in heart failure: national guidance. Heart 2019;105:904–10. https://doi.org/10.1136/heartjnl-2018-314158
5. Rangaswami J, Bhalla V, Blair JEA et al. Cardiorenal syndrome: classification, pathophysiology, diagnosis, and treatment strategies. A scientific statement from the American Heart Association. Circulation 2019;139:e840–e878. https://doi.org/10.1161/CIR.0000000000000664
