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Cardiorenal Syndrome and the Role of Ultrafiltration in Heart Failure

  • Nonpharmacologic Therapy: Surgery, Ventricular Assist Devices, Biventricular Pacing, and Exercise (AK Hasan, Section Editor)
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Abstract

Acute decompensated heart failure (ADHF) with associated volume overload is the most common cause of hospitalization in heart failure patients. When accompanied by worsening renal function, it is described as a cardiorenal syndrome and is a therapeutic challenge. Initial treatment commonly encompasses intravenous diuretics however, suboptimal results and high rehospitalization rates have led experts to search for alternative therapeutic strategies. Recent technological advances in extracorporeal therapies have made ultrafiltration a feasible option for treatment of hypervolemia in ADHF. Recent large randomized trials have compared the efficacy and safety of ultrafiltration with diuretics. Additionally, the benefits of novel pharmacologic approaches, including combining hypertonic saline with diuretics, have recently been studied. The aim of this review is to discuss the developments in both pharmacologic and extracorporeal methods for treating hypervolemia in ADHF and acute cardiorenal syndrome.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Kellum JA, et al. The 3rd International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI). Int J Artif Organs. 2005;28(5):441–4.

    PubMed  CAS  Google Scholar 

  2. Gheorghiade M, et al. Acute heart failure syndromes: current state and framework for future research. Circulation. 2005;112(25):3958–68.

    Article  PubMed  Google Scholar 

  3. Thom T, et al. Heart disease and stroke statistics–2006 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2006;113(6):e85–e151.

    Article  PubMed  Google Scholar 

  4. Adams Jr KF, et al. Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J. 2005;149(2):209–16.

    Article  PubMed  Google Scholar 

  5. Heywood JT. The cardiorenal syndrome: lessons from the ADHERE database and treatment options. Heart Fail Rev. 2004;9(3):195–201.

    Article  PubMed  Google Scholar 

  6. Metra M, et al. Is worsening renal function an ominous prognostic sign in patients with acute heart failure? The role of congestion and its interaction with renal function. Circ Heart Fail. 2012;5(1):54–62.

    Article  PubMed  Google Scholar 

  7. Hunt SA, et al. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation. 2009;119(14):e391–479.

    Article  PubMed  Google Scholar 

  8. Felker GM, Mentz RJ. Diuretics and ultrafiltration in acute decompensated heart failure. J Am Coll Cardiol. 2012;59(24):2145–53.

    Article  PubMed  CAS  Google Scholar 

  9. • Schrier RW. Role of diminished renal function in cardiovascular mortality: marker or pathogenetic factor? J Am Coll Cardiol. 2006;47(1):1–8. An excellent summary of the relationships between cardiac and renal functions.

    Article  PubMed  Google Scholar 

  10. Schrier RW, et al. Therapy of heart failure. Kidney Int. 2000;57(4):1418–25.

    Article  PubMed  CAS  Google Scholar 

  11. Faris R, et al. Current evidence supporting the role of diuretics in heart failure: a meta analysis of randomised controlled trials. Int J Cardiol. 2002;82(2):149–58.

    Article  PubMed  CAS  Google Scholar 

  12. Ellison DH. Diuretic therapy and resistance in congestive heart failure. Cardiology. 2001;96(3–4):132–43.

    Article  PubMed  CAS  Google Scholar 

  13. Francis GS, et al. Comparison of neuroendocrine activation in patients with left ventricular dysfunction with and without congestive heart failure. A substudy of the Studies of Left Ventricular Dysfunction (SOLVD). Circulation. 1990;82(5):1724–9.

    Article  PubMed  CAS  Google Scholar 

  14. Domanski M, et al. Diuretic use, progressive heart failure, and death in patients in the Studies Of Left Ventricular Dysfunction (SOLVD). J Am Coll Cardiol. 2003;42(4):705–8.

    Article  PubMed  CAS  Google Scholar 

  15. Abdallah JG, et al. Loop diuretic infusion increases thiazide-sensitive Na(+)/Cl(−)-cotransporter abundance: role of aldosterone. J Am Soc Nephrol. 2001;12(7):1335–41.

    PubMed  CAS  Google Scholar 

  16. Hirsch AT, et al. Potential role of the tissue renin-angiotensin system in the pathophysiology of congestive heart failure. Am J Cardiol. 1990;66(11):22D–30D. discussion 30D-32D.

    Article  PubMed  CAS  Google Scholar 

  17. Weber KT. Aldosterone in congestive heart failure. N Engl J Med. 2001;345(23):1689–97.

    Article  PubMed  CAS  Google Scholar 

  18. McCurley JM, et al. Furosemide and the progression of left ventricular dysfunction in experimental heart failure. J Am Coll Cardiol. 2004;44(6):1301–7.

    Article  PubMed  CAS  Google Scholar 

  19. He XR, et al. Effects of furosemide and verapamil on the NaCl dependency of macula densa-mediated renin secretion. Hypertension. 1995;26(1):137–42.

    Article  PubMed  CAS  Google Scholar 

  20. Modena B, et al. Furosemide stimulates renin expression in the kidneys of salt-supplemented rats. Pflugers Arch. 1993;424(5–6):403–9.

    Article  PubMed  CAS  Google Scholar 

  21. Almeshari K, et al. A volume-independent component to postdiuretic sodium retention in humans. J Am Soc Nephrol. 1993;3(12):1878–83.

    PubMed  CAS  Google Scholar 

  22. De Bruyne LK. Mechanisms and management of diuretic resistance in congestive heart failure. Postgrad Med J. 2003;79(931):268–71.

    Article  PubMed  Google Scholar 

  23. Cooper HA, et al. Diuretics and risk of arrhythmic death in patients with left ventricular dysfunction. Circulation. 1999;100(12):1311–5.

    Article  PubMed  CAS  Google Scholar 

  24. • Felker GM, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. 2011;364(9):797–805. DOSE study, largest randomized controlled trial examining diuretic therapy for ADHF.

    Article  PubMed  CAS  Google Scholar 

  25. Butler J, et al. Relationship between heart failure treatment and development of worsening renal function among hospitalized patients. Am Heart J. 2004;147(2):331–8.

    Article  PubMed  Google Scholar 

  26. Felker GM, O'Connor CM, Braunwald E. Loop diuretics in acute decompensated heart failure: necessary? Evil? A necessary evil? Circ Heart Fail. 2009;2(1):56–62.

    Article  PubMed  Google Scholar 

  27. Aronson D, Burger AJ. The relationship between transient and persistent worsening renal function and mortality in patients with acute decompensated heart failure. J Card Fail. 2010;16(7):541–7.

    Article  PubMed  Google Scholar 

  28. Testani JM, et al. Potential effects of aggressive decongestion during the treatment of decompensated heart failure on renal function and survival. Circulation. 2010;122(3):265–72.

    Article  PubMed  Google Scholar 

  29. • Paterna S, et al. Short-term effects of hypertonic saline solution in acute heart failure and long-term effects of a moderate sodium restriction in patients with compensated heart failure with New York Heart Association class III (Class C) (SMAC-HF Study). Am J Med Sci. 2011;342(1):27–37. Largest to date study of the use of Hypertonic Saline Solution in ADHF.

    Article  PubMed  Google Scholar 

  30. Kolff WJ, Leonards JR. Reduction of otherwise intractable edema by dialysis or filtration. Cleve Clin Q. 1954;21(2):61–71.

    PubMed  CAS  Google Scholar 

  31. Ali SS, O.C., Sobotka P. Enhanced sodium extraction with ultrafiltration compared to intravenous diuretics. Heart Failure Society of America 2006 Scientific Meeting; 2006.

  32. Fauchald P. Effects of ultrafiltration on body fluid volumes and transcapillary colloid osmotic gradient in hemodialysis patients. Contrib Nephrol. 1989;74:170–5.

    PubMed  CAS  Google Scholar 

  33. Marenzi G, et al. Interrelation of humoral factors, hemodynamics, and fluid and salt metabolism in congestive heart failure: effects of extracorporeal ultrafiltration. Am J Med. 1993;94(1):49–56.

    Article  PubMed  CAS  Google Scholar 

  34. Agostoni P, et al. 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. Am J Med. 1994;96(3):191–9.

    Article  PubMed  CAS  Google Scholar 

  35. Costanzo MR, et al. Early ultrafiltration in patients with decompensated heart failure and diuretic resistance. J Am Coll Cardiol. 2005;46(11):2047–51.

    Article  PubMed  Google Scholar 

  36. Bart BA, et al. Ultrafiltration versus usual care for hospitalized patients with heart failure: the Relief for Acutely Fluid-Overloaded Patients With Decompensated Congestive Heart Failure (RAPID-CHF) trial. J Am Coll Cardiol. 2005;46(11):2043–6.

    Article  PubMed  Google Scholar 

  37. •• Costanzo MR, et al. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol. 2007;49(6):675–83. UNLOAD trial, the largest randomized controlled trial to date comparing diuretic therapy with ultrafiltration for ADHF.

    Article  PubMed  CAS  Google Scholar 

  38. •• Bart BA, et al. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med. 2012;367(24):2296–304. CARRESS-HF trial, the most recent randomized controlled trial comparing diuretic therapy with ultrafiltration for ADHF with type 1 cardiorenal syndrome.

    Article  PubMed  CAS  Google Scholar 

  39. Aspromonte N, et al. Role of bioimpedance vectorial analysis in cardio-renal syndromes. Semin Nephrol. 2012;32(1):93–9.

    Article  PubMed  Google Scholar 

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Correspondence to Samir V. Parikh.

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Prosek, J., Agarwal, A. & Parikh, S.V. Cardiorenal Syndrome and the Role of Ultrafiltration in Heart Failure. Curr Heart Fail Rep 10, 81–88 (2013). https://doi.org/10.1007/s11897-012-0129-1

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  • DOI: https://doi.org/10.1007/s11897-012-0129-1

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