Acute decompensated heart failure and the cardiorenal syndrome

Abstract

Heart failure is one of the leading causes of hospitalizations in the United States. Concomitant and significant renal dysfunction is common in patients with heart failure. Increasingly, the syndrome of heart failure is one of cardiorenal failure, in which concomitant cardiac and renal dysfunctions exist, with each accelerating the progression of the other. One fourth of patients hospitalized for the treatment of acute decompensated heart failure will experience significant worsening of renal function, which is associated with worse outcomes. It remains unclear whether worsening renal function specifically contributes to poor outcomes or whether it is merely a marker of advanced cardiac and renal dysfunction. Diuretic resistance, with or without worsening renal function, is also common in acute decompensated heart failure, although the definition of diuretic resistance, its prevalence, and prognostic implications are less well defined. The term cardiorenal syndrome has been variably associated with cardiorenal failure, worsening renal function, and diuretic resistance but is more comprehensively defined as a state of advanced cardiorenal dysregulation manifest by one or all of these specific features. The pathophysiology of the cardiorenal syndrome is poorly understood and likely involves interrelated hemodynamic and neurohormonal mechanisms. When conventional therapy for acute decompensated heart failure fails, mechanical fluid removal via ultrafiltration, hemofiltration, or hemodialysis may be needed for refractory volume overload. While ultrafiltration can address diuretic resistance, whether ultrafiltration prevents worsening renal function or improves outcomes in patients with cardiorenal syndrome remains unclear. Evidence regarding the potential renal-preserving effects of nesiritide is mixed, and further studies on the efficacy and safety of different doses of nesiritide in heart failure therapy are warranted. Newer therapeutic agents, including vasopressin antagonists and adenosine antagonists, hold promise for the future, and clinical trials of these agents are underway.

Incidencia e importancia pronóstica del deterioro de la función renal en pacientes hospitalizados con insuficiencia cardiaca

“…Distintos factores en la literatura se han asociado a riesgo de síndrome cardiorenal. Este sín-drome ha tenido definiciones variables [25][26][27] , pero en general se considera un estado en el que existe una alteración de la interacción cardio-renal manifestada por uno o más de de tres hechos específicos. Ellos incluyen IC con enfermedad renal significativa concomitante, deterioro de la función renal durante el tratamiento de la descompensación y resistencia a diuréticos.…”

“…Los factores de riesgo comunes como hipertensión arterial, diabetes mellitus y ateroesclerosis explican la alta coexistencia de disfunción cardiaca y renal 28 . En general los pacientes que desarrollan falla renal son de edad más avanzada, tienen mayor prevalencia de IC, falla renal previa, hipertensión y diabetes [25][26][27] .…”

Fluid Management Strategies in Heart Failure

“…8 Electrolyte levels, hemodynamic parameters, and overall fluid volume status must be carefully monitored and managed. Diuretic resistance is common in patients with advanced heart failure because of hypertrophy of distal tubule epithelial cells, 29 increased activation of the renin-angiotensinaldosterone system, 30 and decreased glomerular filtration rate. 7 Strategies to overcome diuretic resistance are provided in Table 1.…”

“…(Critical Care Nurse. 2012;32 [2]: [20][21][22][23][24][25][26][27][28][29][30][31][32]34) cardiac output, arterial underfilling, activation of neurohormonal systems, and dysregulation between the heart and kidneys. 4 Two large US heart failure registries, Acute Decompensated Heart Failure Registry (ADHERE) 5 and Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) 6 collected data on the clinical features of patients hospitalized for acute decompensated heart failure.…”

Reduction of renal function during mechanical ventilation of healthy lungs in an animal biomodel

“…hod -1 ), creatinine clearance [CrCl = (u-creatinine x urine output)/screatinine; ml.min -1 ], fractional excretion of sodium [FeNa= (uNa/s-Na) / (u-creatinine/s-creatinine); -], glomerular fi ltration index [GFI = u-Na / (u-creatinine/s-creatinine)]; -), free water clearance [Cfw = urine output-(urine output x u-osmolality)/sosmolality; ml.mmol -1 .kg -1 ] and ratio of potassium to sodium in the urine (u-K/u-Na ratio; -) (10). At the end of the procedure, samples of kidney tissue were collected for histological examination.…”