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Renoprotective effect of small volumes of hypertonic saline solution in chronic heart failure patients with marked fluid retention: results of a case-control study

Renoprotektiver Effekt kleiner Volumina hypertoner Kochsalzlösung bei Patienten mit chronischer Herzinsuffizienz und Ödembildung: Ergebnisse einer Fall-Kontroll-Studie

Abstract

During intensive therapy of chronic heart failure (CHF) patients with marked fluid retention using high doses of i.v. furosemide the additional effect of agents which might exert osmotic attraction of interstitial fluids has been proposed. They are thought to impede the impairment of renal blood supply and glomerular filtration rate, which may be caused by a combined action of cardiac preload acute reduction, hypotension and neurohormonal activation.

We therefore assessed in CHF patients with NYHA class III and BNP values from 900 to 1500 pg/ml, who were treated with i.v. furosemide, the predictors of iatrogenic short term creatinine impairment by means of a case-control observational study from two centers. Patients with CHF had been treated for 6–8 days with intravenous loop diuretics alone or with an additional i.v. administration of other agents (plasma expanders, albumin, mannitol, inotropic support etc.). A rise in serum creatinine ≥25% of the basal value was considered as renal impairment.

A total of 15 cases and 38 controls were enrolled. At univariate analysis, serum creatinine basal value ≥2.2 mg/dl, absence of hypertonic saline solution (HSS) in the therapeutic protocol, hyposodic diet and refractory oligoanuria were associated with an increased risk of worsening renal function precipitated by i.v. diuretic therapy. At multivariate analysis as a predictor of loop diuretic-related renal function impairment, we found a serum creatinine ≥2.2 mg/dl at baseline (OR: 63.33, 95% CI: 3.68–1088.73, p=0.0043) and the absence of HSS in the therapeutic regimen (OR: 25.0461, 95% CI: 2.07–302.53, p=0.0113). Moreover, in multivariate analysis ascites had some predictive value of renal deterioration (OR: 13.28, 95% CI: 1.0055–175.41, p=0,0495).

Zusammenfassung

Bei intensivpflichtigen Patienten mit chronischer Herzinsuffizienz (CHI) und Ödembildung kann bei i.v.-Gabe von Schleifendiuretika (z. B. Furosemid) ein Anstieg der Kreatininwerte beobachtet werden. Die zusätzliche Gabe von Substanzen, die einen osmotischen Einfluss auf die vermehrte Gewebsflüssigkeit haben, könnte die für den Kreatininanstieg verantwortlich gemachte Verminderung der Durchblutung der Niere und der glomerulären Filtrationsrate, welche durch Vorlastreduktion, Hypotension und neurohormonale Aktivierung verursacht wurden, günstig beeinflussen.

Wir untersuchten deshalb bei Patienten mit CHI der NYHA-Klasse III und mit erhöhten BNP-Spiegeln (900–1500 pg/ml), die i.v. mit Furosemid behandelt wurden, die Prädiktoren eines iatrogenen kurzfristigen Kreatininanstiegs im Rahmen einer Fall-Kontroll-Studie zweier Zentren. Voraussetzung für den Studieneinschluss war die Behandlung der CHI-Patienten über 6–8 Tage mit i.v.-Schleifendiuretika und ein Kreatininanstieg von ≥25% des Ausgangswerts.

Es wurden 15 CHI-Fälle und 38 Kontrollen untersucht. Bei univariater Analyse waren die Determinanten eines relevanten Kreatininanstiegs ein Ausgangswert des Serumkreatinins von ≥2,2 mg/dl, das Fehlen hypertoner Kochsalzlösung im therapeutischen Protokoll, salzarme Diät sowie eine Oligoanurie. Bei multivariater Analyse verblieben als Prädiktoren einer Beeinträchtigung der Nierenfunktion, die durch ein Schleifendiuretikum ausgelöst wird, ein Ausgangswert des Serumkreatinins von ≥2,2 mg/dl (OR:63,33 95%CI: 3,68–1088,73 p=0,0043) und das Fehlen der hypertonen Kochsalzlösung in der Therapie (OR: 25,0461 95%CI: 2,07–302,53 p=0,0113). Außerdem war Aszites bei der multivariaten Analyse ein negativer Prädiktor (OR: 13,28 95%CI:1,0055–175,41; p=0,0495).

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De Vecchis, R., Ciccarelli, A., Ariano, C. et al. Renoprotective effect of small volumes of hypertonic saline solution in chronic heart failure patients with marked fluid retention: results of a case-control study. Herz 36, 12–17 (2011). https://doi.org/10.1007/s00059-010-3394-3

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  • DOI: https://doi.org/10.1007/s00059-010-3394-3

Keywords

  • Chronic heart failure
  • Hydrosaline retention
  • Intravenous diuretics
  • Renal dysfunction
  • Hypertonic saline solution

Schlüsselwörter

  • Chronische Herzinsuffizienz
  • Flüssigkeitsretention
  • Intravenöse Diuretika
  • Nierendysfunktion
  • Hypertone Kochsalzlösung