Potential Effects of Aggressive Decongestion During the Treatment of Decompensated Heart Failure on Renal Function and Survival

Abstract

Background-Overly aggressive diuresis leading to intravascular volume depletion has been proposed as a cause for worsening renal function during the treatment of decompensated heart failure. If diuresis occurs at a rate greater than extravascular fluid can refill the intravascular space, the concentration of such intravascular substances as hemoglobin and plasma proteins increases. We hypothesized that hemoconcentration would be associated with worsening renal function and possibly would provide insight into the relationship between aggressive decongestion and outcomes. Methods and Results-Subjects in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery CatheterizationEffectiveness trial limited data set with a baseline/discharge pair of hematocrit, albumin, or total protein values were included (336 patients). Baseline-to-discharge increases in these parameters were evaluated, and patients with Ն2 in the top tertile were considered to have evidence of hemoconcentration. The group experiencing hemoconcentration received higher doses of loop diuretics, lost more weight/fluid, and had greater reductions in filling pressures (PϽ0.05 for all).Hemoconcentration was strongly associated with worsening renal function (odds ratio, 5.3; PϽ0.001), whereas changes in right atrial pressure (Pϭ0.36) and pulmonary capillary wedge pressure (Pϭ0.53) were not. Patients with hemoconcentration had significantly lower 180-day mortality (hazard ratio, 0.31; Pϭ0.013). This relationship persisted after adjustment for baseline characteristics (hazard ratio, 0.16; Pϭ0.001). Conclusion-Hemoconcentration

The association between high‐dose loop diuretic use at discharge and cardiovascular mortality in patients with heart failure

“…According to a previous study, the renal impairment in HF patients is associated with poor prognosis 21. However, some recent studies suggested that the beneficial effect of aggressive decongestion during treatment persisted after hospital discharge in HF patients with and without worsening renal function 7, 8. We observed that both serum creatinine and BNP were higher in the HD group than in the LD group.…”

“…Generally speaking, loop diuretics are prescribed in 70–90% of patients with chronic HF 3, 5, 6. Some studies showed that aggressive decongestion had a beneficial effect on survival in these patients 7, 8. However, other studies have suggested that high‐dose loop diuretics were associated with poor prognosis in HF patients 9, 10.…”

Decongestive Therapy and Renal Function in Acute Heart Failure

“…7 Recently, several retrospective analyses from completed trials have suggested that it may be important to consider the time course of WRF and the relationship of WRF to the degree of decongestion achieved, but even in those analyses, the best outcomes are clearly in those patients who achieve clinical decongestion while preserving renal function. [8][9][10] Until a prospective trial clearly establishes that any form of WRF is safe during treatment of AHF, it is reasonable to assume that the goal of treatment should be adequate clinical decongestion without causing renal dysfunction (or worsening it if already present). Because reliance on changes in serum creatinine does not distinguish among the various causes of WRF, and because it may be important in particular to know whether true acute kidney injury occurs, the use of new biomarkers, such as cystatin C, KIM 1 (kidney injury molecule-1), and urinary natriuretic peptides, may lead to enhanced understanding of the nature and implication of mechanisms underlying WRF in future trials.…”

Worsening renal function definition is insufficient for evaluating acute renal failure in acute heart failure

“…Furthermore, bolus infusions do not promote gradual diuresis and therefore do not allow time for the fluid in the periphery to move from the extravascular to the intravascular space, which leads to intravascular volume depletion and significant drops in renal perfusion, subsequently leading to renal dysfunction 23. Aggressive decongestion therefore leads to transit renal dysfunction during the acute phase of AHF; however, current research suggested that transient renal dysfunction with the use of high‐dose diuretics was associated with early clinical improvement and not a poor outcome 23, 24. It was reported recently that some mechanisms of the renal dysfunction were not associated with an adverse outcome in patients with AHF.…”