Acute decompensated heart failure and the cardiorenal syndrome.
Acute decompensated heart failure and the cardiorenal syndrome.
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DOI：
10.1097/01.ccm.0000296270.41256.5c
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发表时间：
2008-01-01
影响因子：
8.8
通讯作者：
Redfield, Margaret M
中科院分区：
文献类型：
--
作者：
Liang, Kelly V;Williams, Amy W;Redfield, Margaret M
心力衰竭是美国住院的主要原因之一。心力衰竭患者中常见伴发和显著肾功能不全。越来越多的心力衰竭综合征是心肾功能衰竭的一种，其中存在伴随的心脏和肾功能障碍，每种都加速了另一种的进展。四分之一住院治疗急性失代偿性心力衰竭的患者将经历肾功能显著恶化，这与更差的结局相关。目前尚不清楚肾功能恶化是否会导致不良结局，或者它是否仅仅是晚期心肾功能不全的标志。利尿剂抵抗，伴或不伴肾功能恶化，在急性失代偿性心力衰竭中也很常见，尽管利尿剂抵抗的定义、患病率和预后意义尚不明确。术语心肾综合征与心肾功能衰竭、肾功能恶化和利尿剂抵抗相关，但更全面地定义为表现为一种或所有这些特定特征的晚期心肾失调状态。心肾综合征的病理生理机制知之甚少，可能涉及相互关联的血流动力学和神经激素机制。当急性失代偿性心力衰竭的常规治疗失败时，可能需要通过超滤、血液滤过或血液透析进行机械液体清除以治疗难治性容量超负荷。虽然超滤可以解决利尿剂抵抗，但超滤是否可以防止心肾综合征患者的肾功能恶化或改善结局仍不清楚。关于奈西立肽潜在的肾脏保护作用的证据是混合的，需要进一步研究不同剂量奈西立肽在心力衰竭治疗中的有效性和安全性。新的治疗药物，包括加压素拮抗剂和腺苷拮抗剂，为未来带来希望，这些药物的临床试验正在进行中。
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.