Importance of Venous Congestion for Worsening of Renal Function in Advanced Decompensated Heart Failure

Abstract

Background Reduced cardiac output is traditionally believed to be the main determinant of worsening renal function (WRF) in advanced decompensated heart failure (ADHF). Objective To determine if venous congestion, rather than impairment of cardiac output, is primarily associated with the development of WRF in ADHF. Methods A total of 145 consecutive patients admitted with ADHF treated with intensive medical therapy guided by pulmonary artery catheter were studied. WRF was defined as an increase of serum creatinine ≥0.3 mg/dl during hospitalization. Results In the study cohort (age 57 ±14 years, cardiac index 1.9 ±0.6 l/kg.m2, LVEF 20 ±8%, serum creatinine 1.7 ±0.9 mg/dl), 58 patients (40%) developed WRF. Patients who developed WRF had a higher central venous pressure on admission (CVP, 18 ±7 versus 12 ±6 mmHg, p<0.001) and after intensive medical therapy (11 ±8 versus 8 ±5 mmHg, p=0.04). The development of WRF occurred less frequently in patients that achieved a CVP <8 mmHg (p=0.01). Furthermore, the ability of CVP to stratify risk for development of WRF was apparent across the spectrum of systemic blood pressure, pulmonary capillary wedge pressure, cardiac index, and estimated glomerular filtration rates. Conclusions Venous congestion is the most important hemodynamic factor driving WRF in decompensated patients with advanced heart failure.

Loop Diuretic Therapy in Heart Failure: The Need for Solid Evidence on a Fluid Issue

“…Venous congestion, not diuretic use, was the strongest determinant for the development of WRF. 23 Discussion HF treatment has changed tremendously over the last 2 decades, most notably with medications that inhibit RAAS and SNS. 24 Loop diuretics have been utilized prior to our full understanding of the roles of RAAS and SNS in HF pathophysiology.…”

Worsening renal function definition is insufficient for evaluating acute renal failure in acute heart failure

“…Traditionally, AKI has been attributed to hypoperfusion of the kidney because of progressive impairment of the cardiac output 15. However, attention has shifted from this cardiac output (‘forward failure’) to venous congestion (‘backward failure’) as the most important haemodynamic determinant 1. Current evidences did not support low cardiac output as the main determinant of renal dysfunction in patients with AHF 1, 16.…”

“…However, attention has shifted from this cardiac output (‘forward failure’) to venous congestion (‘backward failure’) as the most important haemodynamic determinant 1. Current evidences did not support low cardiac output as the main determinant of renal dysfunction in patients with AHF 1, 16. The development of ‘congestive kidney failure’ induced by the increased renal venous pressure arising from venous congestion (increased renal afterload) and increased renal interstitial pressure (intrinsic renal compromise) might be important mechanisms underlying the development of renal dysfunction in AHF patients 1…”

Cardiac resynchronization therapy outcomes in patients under nonoptimal medical therapy

“…However, we have shown that the optimization of pharmacological treatment during the first year of follow‐up was associated with a relative risk reduction of HF/death, which suggests a complementary effect of CRT and up‐titration of pharmacological therapy. The reason for this improvement might be that CRT provides acute hemodynamic improvement,19, 20, 21, 22 with an increase in cardiac output and a reduction in pulmonary capillary wedge and improvement in the mechanical activation sequence. Cardiac resynchronization therapy also supports systemic blood pressure and heart rate, enabling an increase in the doses of drugs without the associated risk of lethal bradycardia and hypotension.…”