SUSTAINED IMPROVEMENT IN FUNCTIONAL-CAPACITY AFTER REMOVAL OF BODY-FLUID WITH ISOLATED ULTRAFILTRATION IN CHRONIC CARDIAC-INSUFFICIENCY - FAILURE OF FUROSEMIDE TO PROVIDE THE SAME RESULT
SUSTAINED IMPROVEMENT IN FUNCTIONAL-CAPACITY AFTER REMOVAL OF BODY-FLUID WITH ISOLATED ULTRAFILTRATION IN CHRONIC CARDIAC-INSUFFICIENCY - FAILURE OF FUROSEMIDE TO PROVIDE THE SAME RESULT
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DOI：
10.1016/0002-9343(94)90142-2
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发表时间：
1994-03-01
影响因子：
5.9
通讯作者：
GUAZZI, MD
中科院分区：
文献类型：
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作者：
AGOSTONI, P;MARENZI, G;GUAZZI, MD
目的：本研究旨在探讨中度充血性心力衰竭患者肺间质液体亚临床蓄积是否干扰患者的功能能力，以及速尿治疗是否能促进过量液体的重吸收。背景：在中度充血性心力衰竭患者中，即使优化治疗以保持尿量正常，并防止体重增加和依赖性水肿的形成，胸部X线片仍可检测到肺水分过多。去除过多的水分可能有助于确定其意义。方法：地高辛、口服速尿和血管紧张素转换酶(ACE)抑制剂治疗方案保持不变的患者随机分为超滤组(8例)或静脉推注补充速尿(平均剂量：248 mg；8例)。每种方法排出的体液量约为1600毫升。结果：两种方法撤液后即刻，大鼠双侧脑室充盈压下降，体重下降，血浆肾素活性、去甲肾上腺素和醛固酮水平升高。服用速尿后，激素水平在接下来的4天内持续升高，在此期间，患者水代谢阳性，升高的心室充盈压恢复，肺充血复发，但功能能力没有改善。超滤后，肾素、去甲肾上腺素和醛固酮水平在最初的48小时内降至低于控制值，水代谢在新的设定点保持平衡(减少液体摄入量和利尿而不增加体重)。由于肺水重新吸收而产生的良好的循环和呼吸调节改善了这些患者的功能能力。这也可能恢复了肺清除去甲肾上腺素的能力，从而抑制了其促进肾素释放的能力。治疗后3个月继续改善。结论：充血性心力衰竭患者口服速尿治疗后，液体平衡的设定值发生改变，但静脉补充速尿并不改变设定点，至少在联合ACE抑制时不会改变。虽然没有症状，但肺水过多限制了患者的功能能力。
OBJECTIVES: This study was designed to investigate whether a subclinical accumulation of fluid in the lung interstitium associated with moderate congestive heart failure interferes with the patient's functional capacity, and whether furosemide treatment can promote reabsorption of the excessive fluid.BACKGROUND: In patients With moderate congestive heart failure, pulmonary overhydration may be detected by chest roentgenography even if therapy is optimized to keep the urinary output normal and to prevent weight gain and dependent edema formation. Removal of the overhydration may help define its significance.METHODS: Patients, whose regimens of digoxin, oral furosemide, and angiotensin-converting enzyme (ACE) inhibitor therapy were kept constant, were randomly allocated to receive ultrafiltration (8 cases) or an intravenous bolus of supplemental furosemide (mean dose: 248 mg; 8 cases). The amount of body fluid removed with each method approximated 1600 mL. Functional performance was assessed with cardiopulmonary exercise tests.RESULTS: Soon after fluid withdrawal by either method, the filling pressures of the two ventricles and body weight were reduced and plasma renin activity, norepinephrine, and aldosterone were augmented. After furosemide administration, hormone levels remained elevated for the next 4 days, and during this period, patients had positive water metabolism, recovery of the elevated ventricular filling pressures, and reoccurrence of lung congestion with no improvement in functional capacity. After ultrafiltration, levels of renin, norepinephrine, and aldosterone fell to below control values within the first 48 hours and water metabolism was equilibrated at a new set point (less fluid intake and diuresis without weight gain). The favorable circulatory and ventilatory adjustments consequent to the reabsorption of lung water improved the functional capacity of these patients. That may also have restored the lung's ability to clear norepinephrine, thus restraining its facilitation of renin release. The improvement continued 3 months after the procedure.CONCLUSIONS: In patients with congestive heart failure the set point of fluid balance is altered in spite of oral furosemide therapy, supplemental intravenous furosemide does not shift the set point, at least not when combined with ACE inhibition. Excessive, although asymptomatic, lung water limits the functional capacity of the patient.