Kardiorenalna insuficijencija - koncept i terapijski principi

Abstract

A growing number of patients with heart failure have renal insufficiency, which is associated with substantially worse outcome. Term cardiorenal insufficiency describes a pathophysiological condition in which combined cardiac and renal dysfunction amplifies progression of failure of the individual organ. Evidence based medical therapy in these patients is limited by the fact that clinical trials included small fraction of patients with moderate and severe renal insufficiency. Patients with renal impairement should be categorized based on their glomerular filtration rate, rather than by serum creatinine levels. The available data indicate that ACE inhibitors offer a survival advantage in patients with heart failure and mild and moderate renal insufficiency. They should be used cautiously in patients with severe renal insufficiency due to the potential risk for further worsening of the renal function. It appears that the effects of beta-blockers on improved heart failure survival are not affected by impairement of the renal function, but this issue is not yet resolved as very few patients with moderate and severe renal insufficiency were included in clinical mega-trials. Spironolactone should be used with extreme caution, if at all, in patients with advanced renal impairement due to high-risk of potentially life-threatening hyperkalemia. The safety of digoxin in patients with severe renal insufficiency is also unknown, whereas non-steroid antiinflammatory drugs should not be used in this vulnerable population. Statins must be used in these patients, as they have been shown to prolong life. Further studies are needed to asess optimal medical treatment in patients with heart failure and renal insufficiency.