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The combination of decompensated heart failure and kidney failure is frequently referred to as the "cardiorenal syndrome." The cause and pathophysiology of this entity are complex and poorly understood, and treatment options are limited. This report describes 2 patients who were hospitalized for decompensated heart failure and developed diuretic resistance with rapidly worsening renal function. Understanding the underlying causes helped break the cardiorenal syndrome in the first patient but only had a transient beneficial effect in the second patient.

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Objectives: Heart failure (HF) is associated with high mortality and frequent hospitalizations. Disease management programs (DMPs) have a favorable impact on patients with HF. No data exist regarding the outcomes of patients discharged from such a program. Methods: We examined the outcome of patients with severe systolic HF who were discharged from a DMP following full clinical and echocardiographic recovery. Data were reviewed for mortality, emergency room visits, hospitalizations, medication adherence and left ventricular ejection fraction (EF). Results: At enrollment and discharge, the mean EF was 19 and 53%, respectively. At follow-up 46.2 months after discharge, 56% of patients had been to the emergency room, 34% were hospitalized a total of 41 times and 20% had died. In the patients who required hospitalization for HF, the mean EF upon rehospitalization had dropped to 23.4%. Conclusions: Many patients with initially severe systolic HF who had an almost full recovery in a multidisciplinary DMP had very poor outcomes once they were discharged from the program. It may be appropriate to revisit the practice of discharging patients from DMPs once they have reached a specific clinical target.