Abstract
There is mounting evidence that forward heart failure as manifested by low cardiac output alone does not define the degree of renal dysfunction in cardiorenal syndrome. As a result, the term “congestive renal failure” was coined in 2012 by Ross to depict the role of renal venous hypertension in type 1 acute cardiorenal syndrome. If so, aggressive decongestive therapies, either through mechanical ultrafiltration with dialysis machines or pharmacologic ultrafiltration with potent diuretics, would lead to improved cardio and renal outcomes. Nevertheless, as recently as 2012, a review of this literature had concluded that a renal venous hypertension-directed approach using diuretics to manage cardio-renal syndrome was yet to be fully investigated. We, in this review, with three consecutive case series, describe our experience with pharmacologic decongestive diuresis in this paradigm of care and argue for studies of such therapeutic interventions in the management of cardiorenal syndrome. Finally, based on our observations in the Renal Unit, Mayo Clinic Health System, in Northwestern Wisconsin, we have hypothesized that patients with cardiorenal syndrome presenting with accelerated rising Pro B Naturetic Peptide levels appear to represent a group that would have good cardio- and renal-outcomes with such decongestive pharmacologic therapies.
Highlights
In early March 2017, the Nephrology service was consulted to see an overweight 83-year-old female patient admitted to the Hospitalist service a week earlier with dyspnea and volume overload from symptomatic heart failure complicated by rapid ventricular response atrial fibrillation, against a background history of hypertension and stage 3 CKD
We have demonstrated very impressive degrees of diuresis in three consecutive patients with symptomatic heart failure, associated worsening renal failure consistent with cardiorenal syndrome, symptomatic heart failure, associated worsening renal failure consistent with cardiorenal syndrome, following the utilization of the combination of continuous intravenous Furosemide infusion with following the utilization of the combination of continuous intravenous Furosemide infusion with intravenous Chlorothiazide given every 8–12 h
Symptomatic heart failure relief with loss of edema and anasarca fluid, weight loss, improvement in dyspnea and orthopnea, as well as simultaneous and anasarca fluid, weight loss, improvement in dyspnea and orthopnea, as well as simultaneous improvement in renal function was achieved in all three patients in our series
Summary
This review called for larger and more rigorous trials to definitely establish under what circumstances conventional pharmacologic and ultrafiltration goals might best be directed towards central venous pressures rather than left ventricular or cardiac output parameters [1] The mission of this manuscript is to describe our experience with three patients presenting to the Renal Unit, Mayo Clinic Health System, Eau Claire, in Northwestern Wisconsin, over three months, May–June 2017, with features of worsening symptomatic congestive heart failure or acute decompensating heart failure with concurrent worsening acute kidney injury (cardiorenal syndrome) and the response of these patients to conventional pharmacologic diuresis, leading to improvement in both heart failure symptoms and acute kidney injury. Such therapeutic maneuvers would prove invaluable to practitioners in resource-poor settings without access to mechanical ultrafiltration with dialysis or similar equipment
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