Der Nephrologe

, Volume 4, Issue 2, pp 177–191

Diuretika bei Herzinsuffizienz

CME Weiterbildung • Zertifizierte Fortbildung

Zusammenfassung

Diuretika sind bei der akuten kardialen Dekompensation notwendige, unersetzliche Medikamente zur Behandlung der pulmonalen und peripheren Überwässerung. Auch der Einsatz von Diuretika bei arterieller Hypertonie in Form von niedrigdosierten Thiaziden ist etabliert. Bei akuter Herzinsuffizienz werden Diuretika zur symptomatischen Therapie der Überwässerung empfohlen. Ein Nutzen von Diuretika bezüglich harter Endpunkte bei chronischer Herzinsuffizienz ist bisher nicht nachgewiesen. Doch evidenzbasiert ist, dass eine suffiziente neurohumorale Blockade des Renin-Angiotensin-Aldosteron-Systems (RAAS) und des Sympathikus (SNS) das Risiko von Natrium- und Flüssigkeitsrestriktion, die Dekompensation und die Mortalität drastisch reduzieren kann. Einsatz finden Schleifen- und Thiaziddiuretika sowie kaliumsparende Diuretika. Nebenwirkungen sind u. a. Elektrolytentgleisungen, Azidose/Alkalose, Insulinresistenz und Ototoxizität. Der Einsatz von Diuretika beim Nierenversagen hat keinen oder sogar einen nachteiligen Einfluss auf die Erholung der Nierenfunktion, nicht kaliumsparende Diuretika führen vermutlich sogar zu einer Erhöhung der Mortalität durch maligne Arrhythmien. Eine sequenzielle Tubulusblockade und/oder eine passagere Ultrafiltration bzw. Nierenersatztherapie können bei renokardialen Syndromen und Resistenz auf die konventionelle Therapie möglicherweise von Nutzen sein, Evidenz aus kontrollierten Studien fehlt bis heute.

Schlüsselwörter

Diuretika Herzinsuffizienz Dekompensation Elektrolytentgleisung 

Diuretics in heart failure

Abstract

Diuretics are useful and inevitable in acute congestive heart failure with pulmonary congestion and edema. The use of low-dose thiazide diuretics is well established in arterial hypertension. In acute heart failure, diuretics are recommended for the treatment of fluid overload and pulmonary edema. No evidence is available so far regarding any benefit of diuretics on the outcome of patients with chronic heart failure, whereas evidence-based blockade of the renin-angiotensin system and sympathetic nervous system reduces the risk of congestion and improves survival. Several types of diuretics are relevant: loop diuretics, thiazides, and potassium-sparing diuretics. All diuretics have significant side effects, mainly electrolyte disorders, metabolic acidosis/alkalosis, insulin resistance, and ototoxicity. Diuretics have no benefit in acute or acute-on-chronic renal failure; moreover, they even increase mortality and reduce the chance of renal recovery in these patients. Increased mortality with the use of diuretics also seems to be associated with a higher risk of lethal arrhythmias. Sequential tubular blockade may be useful for the short term in potentiating the natriuresis in renocardiac syndromes. Furthermore, ultrafiltration or renal replacement therapy may have an additional beneficial effect in these patients, although controlled trials are still lacking.

Keywords

Diuretics Congestive heart failure Congestion Electrolyte disorders 

Literatur

  1. 1.
    Batlle DC, Von Riotte AB, Gaviria M, Grupp M (1985) Amelioration of polyuria by amiloride in patients receiving long-term lithium therapy. N Engl J Med 312:408–414PubMedCrossRefGoogle Scholar
  2. 2.
    Bock HA, Stein JH (1988) Diuretics and the control of extracellular fluid volume: role of counterregulation. Semin Nephrol 8:264–272PubMedGoogle Scholar
  3. 3.
    Brater DC (1998) Diuretic therapy. N Engl J Med 339:387–395PubMedCrossRefGoogle Scholar
  4. 4.
    Brilla CG, Matsubara LS, Weber KT (1993) Antifibrotic effects of spironolactone in preventing myocardial fibrosis in systemic arterial hypertension. Am J Cardiol 71:12A–16APubMedCrossRefGoogle Scholar
  5. 5.
    Cooper HA, Dries DL, Davis CE et al (1999) Diuretics and risk of arrhythmic death in patients with left ventricular dysfunction. Circulation 100:1311–1315PubMedGoogle Scholar
  6. 6.
    Costanzo MR, Guglin ME, Saltzberg MT et al (2007) Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol 49:675–683PubMedCrossRefGoogle Scholar
  7. 7.
    Dai LJ, Friedman PA, Quamme GA (1997) Cellular mechanisms of chlorothiazide and cellular potassium depletion on Mg2+ uptake in mouse distal convoluted tubule cells. Kidney Int 51:1008–1017PubMedCrossRefGoogle Scholar
  8. 8.
    Dickstein K, Cohen-Solal A, Filippatos G et al (2008) ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM). Eur Heart J 29:2388–2442PubMedCrossRefGoogle Scholar
  9. 9.
    Domanski M, Norman J, Pitt B et al (2003) Diuretic use, progressive heart failure and death in patients in the Studies Of Left Ventricular Dysfunction (SOLVD). J Am Coll Cardiol 42:705–708PubMedCrossRefGoogle Scholar
  10. 10.
    Dyckner T, Wester PO, Widman L (1988) Amiloride prevents thiazide-induced intracellular potassium and magnesium losses. Acta Med Scand 224:25–30PubMedGoogle Scholar
  11. 11.
    Elliott WJ, Meyer PM (2007) Incident diabetes in clinical trials of antihypertensive drugs: a network meta-analysis. Lancet 369:201–207PubMedCrossRefGoogle Scholar
  12. 12.
    Ellison DH (1991) The physiologic basis of diuretic synergism: its role in treating diuretic resistance. Ann Intern Med 114:886–894PubMedGoogle Scholar
  13. 13.
    Fliser D, Haller H (2004) Modern differential therapy with diuretics. Internist (Berl) 45:598–605Google Scholar
  14. 14.
    Galve E, Mallol A, Catalan R et al (2005) Clinical and neurohumoral consequences of diuretic withdrawal in patients with chronic, stabilized heart failure and systolic dysfunction. Eur J Heart Fail 7:892–898PubMedCrossRefGoogle Scholar
  15. 15.
    Hawkins RG, Houston MC (2005) Is population-wide diuretic use directly associated with the incidence of end-stage renal disease in the United States? A hypothesis. Am J Hypertens 18:744–749PubMedCrossRefGoogle Scholar
  16. 16.
    Higgins BA, Nassim JR, Collins J, Hilb A (1964) The effect of bendrofluazide on urine calcium excretion. Clin Sci 27:457–462PubMedGoogle Scholar
  17. 17.
    Huen SC, Goldfarb DS (2007) Adverse metabolic side effects of thiazides: implications for patients with calcium nephrolithiasis. J Urol 177:1238–1243PubMedCrossRefGoogle Scholar
  18. 18.
    Kagan A, Rapoport J (2005) The role of peritoneal dialysis in the treatment of refractory heart failure. Nephrol Dial Transplant 20(suppl 7):vii28–31PubMedCrossRefGoogle Scholar
  19. 19.
    Karalliedde J, Buckingham RE (2007) Thiazolidinediones and their fluid-related adverse effects: facts, fiction and putative management strategies. Drug Saf 30:741–753PubMedCrossRefGoogle Scholar
  20. 20.
    Klamerus KJ (1986) Current concepts in clinical therapeutics: congestive heart failure. Clin Pharm 5:481–498PubMedGoogle Scholar
  21. 21.
    Knauf H, Mutschler E (1984) Pharmacodynamics and pharmacokinetics of xipamide in patients with normal and impaired kidney function. Eur J Clin Pharmacol 26:513–520PubMedCrossRefGoogle Scholar
  22. 22.
    Konig P, Geissler D, Lechleitner P et al (1987) Improved management of congestive heart failure. Use of continuous ambulatory peritoneal dialysis. Arch Intern Med 147:1031–1034PubMedCrossRefGoogle Scholar
  23. 23.
    Lassnigg A, Donner E, Grubhofer G et al (2000) Lack of renoprotective effects of dopamine and furosemide during cardiac surgery. J Am Soc Nephrol 11:97–104PubMedGoogle Scholar
  24. 24.
    Law MR, Wald NJ, Morris JK, Jordan RE (2003) Value of low dose combination treatment with blood pressure lowering drugs: analysis of 354 randomised trials. BMJ 326:1427PubMedCrossRefGoogle Scholar
  25. 25.
    Lehrich RW, Greenberg A (2008) When is it appropriate to use vasopressin receptor antagonists? J Am Soc Nephrol 19:1054–1058PubMedCrossRefGoogle Scholar
  26. 26.
    Loon NR, Wilcox CS, Unwin RJ (1989) Mechanism of impaired natriuretic response to furosemide during prolonged therapy. Kidney Int 36:682–689PubMedCrossRefGoogle Scholar
  27. 27.
    Maronde RF, Milgrom M, Vlachakis ND, Chan L (1983) Response of thiazide-induced hypokalemia to amiloride. JAMA 249:237–241PubMedCrossRefGoogle Scholar
  28. 28.
    Mccurley JM, Hanlon SU, Wei SK et al (2004) Furosemide and the progression of left ventricular dysfunction in experimental heart failure. J Am Coll Cardiol 44:1301–1307PubMedCrossRefGoogle Scholar
  29. 29.
    Mehta RL, Pascual MT, Soroko S, Chertow GM (2002) Diuretics, mortality and nonrecovery of renal function in acute renal failure. JAMA 288:2547–2553PubMedCrossRefGoogle Scholar
  30. 30.
    Nieminen MS, Bohm M, Cowie MR et al (2005) Executive summary of the guidelines on the diagnosis and treatment of acute heart failure: the Task Force on Acute Heart Failure of the European Society of Cardiology. Eur Heart J 26:384–416PubMedCrossRefGoogle Scholar
  31. 31.
    Perez AV, Dietz R, Rauchhaus M (2008) Are diuretics overused in the treatment of chronic heart failure? Nat Clin Pract 5:238–239Google Scholar
  32. 32.
    Philipp T (2008) Diuretika. In: Wolff-Weihrauch (Hrsg) Internistische Therapie. Elsevier, Amsterdam, p 147–160Google Scholar
  33. 33.
    Ram CV, Garrett BN, Kaplan NM (1981) Moderate sodium restriction and various diuretics in the treatment of hypertension. Arch Intern Med 141:1015–1019PubMedCrossRefGoogle Scholar
  34. 34.
    Ronco C, Haapio M, House AA et al (2008) Cardiorenal syndrome. J Am Coll Cardiol 52:1527–1539PubMedCrossRefGoogle Scholar
  35. 35.
    Salvador DR, Rey NR, Ramos GC, Punzalan FE (2004) Continuous infusion versus bolus injection of loop diuretics in congestive heart failure. Cochrane Database Syst Rev:CD003178Google Scholar
  36. 36.
    Sandhofer A, Kahler C, Heininger D et al (2002) Severe electrolyte disturbances and renal failure in elderly patients with combined diuretic therapy including xipamid. Wien Klin Wochenschr 114:938–942PubMedGoogle Scholar
  37. 37.
    Schneider D, Richling F (2008) Checkliste Arzneimittel A–Z. Thieme, StuttgartGoogle Scholar
  38. 38.
    Schrier RW, Gross P, Gheorghiade M et al (2006) Tolvaptan, a selective oral vasopressin V2-receptor antagonist, for hyponatremia. N Engl J Med 355:2099–2112PubMedCrossRefGoogle Scholar
  39. 39.
    Swedberg K, Cleland J, Dargie H et al (2005) Guidelines for the diagnosis and treatment of chronic heart failure: executive summary (update 2005): The Task Force for the Diagnosis and Treatment of Chronic Heart Failure of the European Society of Cardiology. Eur Heart J 26:1115–1140PubMedCrossRefGoogle Scholar
  40. 40.
    Velazquez H (1987) Thiazide diuretics. Ren Physiol 10:184–197PubMedCrossRefGoogle Scholar
  41. 41.
    Verdel BM, van Puijenbroek EP, Souverein PC et al (2008) Drug-related nephrotoxic and ototoxic reactions: a link through a predictive mechanistic commonality. Drug Saf 31:877–884PubMedCrossRefGoogle Scholar
  42. 42.
    Wenzel RR (2006) Role of angiotensin-1-receptor blockers in cardiorenal disease. Curr Drug Ther 1:47–54CrossRefGoogle Scholar
  43. 43.
    Wenzel RR, Bruck H, Noll G et al (2000) Antihypertensive drugs and the sympathetic nervous system. J Cardiovasc Pharmacol 35:S43–S52PubMedCrossRefGoogle Scholar
  44. 44.
    Bagshaw SM, Brophy PD, Cruz D, Ronco C (2008) Fluid balance as a biomarker: impact of fluid overload on outcome in critically ill patients with acute kidney injury. Crit Care 12:169PubMedCrossRefGoogle Scholar
  45. 45.
    Sica DA, Nephron Gehr TW (1989) Triamterene and the kidney. Nephron 51:454–461PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2009

Authors and Affiliations

  1. 1.Abteilung für Innere Medizin, Kardiologie und NephrologieAllgemeines öffentliches Krankenhaus Zell am See, Akademisches Lehrkrankenhaus der Paracelsus Universitätsklinik SalzburgZell am SeeÖsterreich

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