Trends in the management of cardiac patients with renal functional impairment

Abstract

Treatment of acute decompensated heart failure is challenging, especially in that traditional diuretic approaches can worsen the cardiorenal syndrome, with activation of the renin-angiotensin-aldosterone and sympathetic nervous systems. A variety of alternative pharmacologic therapies have been used with limited success, including inotropes, natriuretics, aquaretics, and erythropoiesis-stimulating agents, and trials with adenosine receptor antagonists are ongoing. It has been proposed that salt and water removal by nonrenal or extracorporeal means would avoid maladaptive tubuloglomerular feedback neurohumoral mechanisms induced by diuretics. This has been the rationale for a growing literature supporting the use of paracentesis, ultrafiltration by peritoneal dialysis modalities, and extracorporeal therapies such as slow continuous ultrafiltration. The latter are appealing in that there is existing technology as well as newly developed machines dedicated to this technique. Use of these mechanical fluid removal therapies, however, warrants caution because of the risks of excess fluid removal, hypotension, acute kidney injury, and blood or air leaks inherent in blood-pumped modalities. © 2010 Springer-Verlag Milan.