Cardio-Renal Syndrome: Epidemiological Aspect in the Medicine Department of Tombouctou Hospital ()
1. Introduction
Cardio-renal syndrome is a pathophysiological disorder of the heart and kidneys in which chronic or acute dysfunction of one can lead to chronic or acute dysfunction of the other [1]. Cardio-renal syndrome is classified by Ronco [2] into five subtypes (Table 1).
His diagnosis is made on the basis of a picture of clinical heart failure with impaired renal function.
According to the US ADHERE registry, at least 65% of patients with a picture of acute heart failure have a creatinine clearance < 60 ml/min [3].
In Africa, the prevalence of the cardio-renal syndrome is little assessed in cardiology settings; in Senegal, a study conducted in a cardiology department in Dakar found 3.7% [1].
In Mali, no study has dealt with this aspect of the cardio-renal syndrome, hence the interest of our study.
The objective of this work was to determine the hospital prevalence of cardio-renal syndrome in the Medical Department of the Tombouctou Hospital in Mali.
2. Material and Method
This was a descriptive transversal study carried out in the medical department of the Tombouctou hospital from January 2020 to June 2021, during which we included 75 patients with heart failure associated with impaired renal function.
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Table 1. RONCO classification of cardio-renal syndrome.
CRS: Cardio-renal syndrome.
The volunteers were patients hospitalized with heart failure and impaired kidney function. After obtaining informed consent, they were included in the study.
2.1. Collection of Data
Data collection was done from hospital records.
The data collected were socio-demographic, clinical (functional signs, physical signs), cardiovascular and para-clinical risk factors (trans-thoracic echocardiography, renal ultrasound, biological: blood count, glycemia, creatinemia, ionogramblood).
2.2. Judging Criteria
Clinical: patients with symptoms suggestive of heart failure.
The positive diagnosis of cardio-renal syndrome was based on:
- a clinical syndrome of heart failure,
- a serum creatinine greater than 1.4 mg/dl in women and 1.3 mg/dl in men.
Claudio Ronco’s classification was used in this work.
2.3. Operational Definitions
Cardio-renal syndrome is a pathophysiological disorder of the heart and kidneys in which chronic or acute dysfunction of one can lead to chronic or acute dysfunction of the other.
Signs of heart failure (HF) were dyspnea (according to NYHA), crackling rales, left galloping noise for left HF and hepatalgia, right galloping noise, hepatomegaly, chest edema, lower limbs, the turgor of the jugular veins for the right CI. Renal impairment was considered for serum creatinine greater than 1.4 mg/dl in women and 1.3 mg/dl in men.
2.4. Variables
Data were collected using the observational medical record and recorded in a questionnaire. This questionnaire was written by the scientific manager and the principal investigator and included.
The statistical population studied was patients with heart failure and impaired renal function.
The variables studied were:
- Quantitative includes the age of the patients, the seniority of hypertension and diabetes, the number of days of hospitalization and of deaths.
- Qualitative included the sex of the patients, symptoms, description of doppler echocardiographic abnormalities and biology. The questionnaire was submitted to a follow-up test on the recruitment procedure and data analysis.
The questionnaire was submitted to a daily quality control before being collected.
Excel 2016 software was used for data collection and then analyzed by SPSS 24 software.
2.5. Ethics
Informed consent was obtained with strict respect for confidentiality.
3. Results
3.1. The General Characteristics of the Studied Population
Out of 1165 hospitalized patients, 75 had cardio-renal syndrome, including 25 women. The hospital prevalence was 6.4%. The average age was 58 with extremes of 18 and 90. Chronic heart failure was the most common medical history (14.6%) (Table 2). Cardiovascular risk factors were dominated by high blood pressure with 50.6%. The mode of discovery was the table of global heart failure (74.6%). The clinical symptoms were dominated by dyspnea (90.6%) and edema of the lower limbs and face (74.6%) accompanied by cough (74.6%). Anemia was noted in 15 patients (20%). The mean serum creatinine was 3.26 mg/dl. The mean MDRD clearance at 32 ml/min. Regular sinus tachycardia was the dominant abnormality on the EKG (42.6%) followed by left ventricular hypertrophy (34.6%) complete arrhythmia with atrial fibrillation (18.6%). The left ventricular ejection fraction was studied by the teicholz method and there was a dilation of the left ventricle (66.6%) associated with an alteration of the systolic function of the left ventricle (64%). The kidney ultrasound performed in 9 patients returned to normal in 8 cases and in 1 patient the kidneys were small.
Chronic heart failure dominated the personal medical history (14.6%) of frequency and global heart failure dominated the circumstances of discovery (74.6%).
3.2. Etiological Factors of CRS
The etiologies of cardio-renal syndrome were dilated cardiomyopathy (46.6%), ischemic heart disease (20%), chronic renal failure (8%), hypertrophic cardiomyopathy (2.6%) and diabetes (2.6%) (Table 3).
According to Ronco’s classification, cardio-renal syndrome type 1 dominated (72%) followed by type 2 (14.6%) (Table 4).
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Table 2. Distribution of patients according to personal medical history and the circumstances of discovery.
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Table 3. Distribution of patients according to etiological factors.
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Table 4. Distribution of patients according to the RONCO classification of cardio-renal syndrome.
Dilated cardiomyopathy and ischemic heart disease dominated the etiologies with 46.6% and 20% frequency, respectively.
It was dominated by type 1,i.e. (72%).
3.3. The Treatment
All the patients benefited from treatment with a diuretic and a sodium-reduced diet. ACE inhibitors were prescribed in 69.3% (52 patients), beta blockers in 18 patients (24%) and calcium channel blockers in 16% (12 patients).
3.4. Hospital Evolution
The duration of hospitalization was 5.4 days. The outcome was favorable in the majority of cases (72%). Complications included 20% refractory heart failure, 8% dialysis and 2.6% cerebral embolism (2 cases). We recorded 8 deaths,i.e. 10.6% lethality. These were refractory heart failure (20%) and stroke (6.6%) Table 5.
4. Discussion
The prevalence of cardio-renal syndrome in our series is of the order of 6.4% higher than the 3.7% of the Dakar study [1] and lower than 65% according to the American ADHERE registry [3] be explained by the financial and security difficulties preventing patients not residing in the city of Tombouctou to consult.
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Table 5. Distribution of patients according to the type of complication under treatment.
The average age was 58 years, higher than the 57.26 ± 16.04 years of kingue [4], but which remains relatively young by agreement in most African studies carried out on heart failure. Unlike in the West, this is a pathology in the subject aged around 70 years [5], this difference is explained by the early management of heart disease and nephropathy as well as risk factors in the West.
The male sex predominated (sex ratio at 2) in phage with Kingue (sex ratio at 1.3) and Bodian (sex ratio at 1.7) unlike Go which had a female predominance at 55% [1] [4] [5]. Arterial hypertension was the most described risk factor 50.6% in line with Lanzy [6] and most of the African but also African-American studies on heart failure [7] [8] [9] [10] [11]. The history was chronic heart failure of hypertensive origin 14.6% and diabetes 6.6% according to Bodian and Sarra [1] [12].
The etiological factors of CRS are dominated by hypertensive dilated cardiomyopathy (46.6%) and ischemic heart disease (20%) in agreement with Bodian [1] and the rest of the literature.
In the majority of cases (72%), the SCR was type 1 versus (97.22%) for type 2 in Bodian [1], our study was carried out in a medical department where all the other medical specialties were there.
In our series, the picture of global heart failure (74.6%) was the most common discovery method, consistent with the rest of the literature [12] [13] [14] [15] explaining the severity of cardio-renal syndrome. Renal damage was biologically constant with a mean creatinine clearance of 32 ml/min. Doppler echocardiography noted dilation of the left ventricle associated with impaired systolic function 64% compared to 71% in Bodian [1].
This difference can be explained by the fact that our study took place in a medical service against the Dakar series in the cardiology service. We recorded a low case fatality rate of 10.6% compared to most of the literature due to the small sample size [1] [16] [17].
The limitations of our study:
The small size of our sample; financial difficulties and the security situation linked to the rebellion in the area prevented patients from being consulted at the hospital.
5. Conclusion
Cardio-renal syndrome is a common feature in which mixed failure is observed in the unfavorable course of heart disease and nephropathy. Its prevalence is unfortunately underestimated in cardiological settings in Africa and in particular in Mali, hence the interest of a more advanced study.
Recommendations
We focus on raising public awareness and health workers on the regular and correct monitoring of high blood pressure.
At the level of political decision-makers: Reinforce accessibility to care.
Research: We believe that prospective and multicentre studies are necessary to better determine the prevalence of CRS in Africa and in Mali in particular.
Acknowledgements
We thank the management of the Tombouctou Hospital for completing the administrative and regulatory formalities for this work, as well as the patients for their trust.
Survey Sheet No.……
1. Socio-Demographic Data
Last name:………………….First name:………………………….Sex:……….
Profession:………………… Residence:…………….......…….Age:…………
2. Reason and Date of Hospitalization
1) pattern:
2) Date: 3) Duration:
3. Personal Background
a) hypertension d) Diabetes
b) chronic kidney failure f) Heart valve disease
c) Heart failure g) others:
4. Cardiovascular Risk Factors
1) Hypertension 4) Age > 60 ans
2) Smoking 5) Obesity
3) Dyslipidemia 6) Famaly history of myocardial infarction
5. Physical Examination
1) General examination
a) Signsof congestions b) others:
2) Cardiac Examination:
6. Futher Examination
1) EKG:
a) Heart rate: c) Hypertrophies
b) Conduction desorders d) Evidence of ischemia
2) Ultrasonic cardiography
a) kinematic: c) Sidewalls:
b) EF: d) Péricardite
3) Biology
a) Blood count formula: b) Urea:
b) Glycemia: d) Creatininemia:
4) Kidney ultrasound:
a) Standard: b) others:
7. Diagnostic
1) CRS Type
a) I c) III e) V
b) II d) IV
2) Cardiomyopathies:
3) Kidney failure:
4) others:
8. Evolution
1) Favorable 2) Death 3) Refer