Management of the Cardiorenal Syndrome in Decompensated Heart Failure

Abstract

Background:The management of the cardiorenal syndrome (CRS) in decompensated heart failure (HF) is challenging, with high-quality evidence lacking. Summary: The pathophysiology of CRS in decompensated HF is complex, with glomerular filtration rate (GFR) and urine output representing different aspects of kidney function. GFR depends on structural factors (number of functional nephrons and integrity of the glomerular membrane) versus hemodynamic alterations (volume status, renal perfusion, arterial blood pressure, central venous pressure or intra-abdominal pressure) and neurohumoral activation. In contrast, urine output and volume homeostasis are mainly a function of the renal tubules. Treatment of CRS in decompensated HF patients should be individualized based on the underlying pathophysiological processes. Key Messages: Congestion, defined as elevated cardiac filling pressures, is not a surrogate for volume overload. Transient decreases in GFR might be accepted during decongestion, but hypotension must be avoided. Paracentesis and compression therapy are essential to remove fluid overload from third spaces. Increasing the effective circulatory volume improves renal function when cardiac output is depressed. As mechanical support is invasive and inotropes are related to increased mortality, afterload reduction through vasodilator therapy remains the preferred strategy in patients who are normo-or hypertensive. Specific therapies to augment renal perfusion (rolofylline, dopamine or nesiritide) have rendered disappointing results, but recently, serelaxin has been shown to improve renal function, even with a trend towards reduced all-cause mortality in selected patients. Diuretic resistance is associated with worse outcomes, independent of the underlying GFR. Combinational diuretic therapy, with ultrafiltration as a bail-out strategy, is indicated in case of diuretic resistance.

Differential Effects of Levosimendan and Dobutamine on Glomerular Filtration Rate in Patients With Heart Failure and Renal Impairment:A Randomized Double‐Blind Controlled Trial

“…It has been assumed that any inotropic drug that displays a favorable effect on central and peripheral hemodynamics would, inevitably, also improve renal function 30. The differential effects of levosimendan and dobutamine on GFR demonstrated by the present study are, therefore, of clinical interest and might imply that levosimendan could be the preferred inotropic agent for treatment of the cardiorenal syndrome.…”

The Renal Arterial Resistance Index Predicts Worsening Renal Function in Chronic Heart Failure Patients

“…Over the last few years, among the factors causing renal injury in cardiorenal syndrome, the role of venous congestion has been widely demonstrated, following that of kidney perfusion and neurohormonal activity [11,13]. The effect of CVP on renal function seems to be mainly related to the increase in the efferent end glomerular capillary pressure that induces a reduction in the net filtration pressure and, consequently, a drop in the GFR [13]. Besides the effects on gradients of renal vasculature, an increased renal venous pressure also causes a rise in the interstitial pressure and an increase in arterial renal resistances.…”

The prevalence of renal dysfunction and its influence on the prognosis of patients with acute heart failure

“…Increases in MAU to >300 mg / l were associated with an unfavorable prognosis; the endpoint was observed in 81.8 % of such patients and ОРИГИНАЛЬНЫЕ СТАТЬИ § Р аспространенность СН и хронических заболеваний почек неуклонно возрастает и будет увеличиваться в дальнейшем в связи со старением населения и улуч-шением лечения СН и заболеваний почек. Поражение почек как органа-мишени часто встречается у паци-ентов с ССЗ, что активирует каскад патологических механизмов в почках и усугубляет прогноз ССЗ [1][2][3][4][5]. Сердечная недостаточность является ФР для развития хронической болезни почек и наоборот, в то же время два этих состояния довольно часто сосуществуют [6].…”