Silverberg Donald, Wexler Dov, Blum Miriam, Wollman Yoram, Iaina Adrian
Department of Nephrology and Department of Cardiology, Tel Aviv Medical Center, Tel Aviv, Israel.
Nephrol Dial Transplant. 2003 Nov;18 Suppl 8:viii7-12. doi: 10.1093/ndt/gfg1084.
Many patients in our nephrology department who have anaemia and chronic kidney insufficiency (CKI) show evidence of congestive heart failure (CHF). This triad of anaemia, CKI and CHF is known as the cardio-renal anaemia syndrome. The three conditions form a vicious circle, in which each condition is capable of causing or being caused by another. Anaemia can increase the severity of CHF and is associated with a rise in mortality, hospitalization and malnutrition. Anaemia can also further worsen renal function and cause a more rapid progression to dialysis than is found in patients without anaemia. Uncontrolled CHF can cause rapid deterioration of renal function and anaemia. CKI can also cause anaemia, as well as worsen the severity of CHF, and is associated with increased mortality and hospitalization in patients with CHF. Aggressive therapy against CHF with all the conventional medications at the accepted doses often fails to improve the CHF if anaemia is also present but is not treated. In studies in which the anaemia was corrected with s.c. erythropoietin and, in some cases, with i.v. iron, however, the cardiac function improved, as assessed by measurement of the left ventricular ejection fraction and oxygen utilization during maximal exercise. Symptomatic patient functioning improved, as monitored by shortness of breath and fatigue on exertion, and the need for hospitalization and oral and i.v. diuretics markedly decreased. The quality of life, as judged by different criteria, also improved. The glomerular filtration rate, which fell rapidly when the anaemia was untreated, stabilized in patients when their anaemia was treated. Nephrologists need to assess the cardiac status of all patients with CKI carefully, and this includes an echocardiogram along with possibly measuring the levels of B-type natriuretic peptide. Nephrologists also need to use the indicated agents for CHF at the recommended doses, while cardiologists and internists need to be more aware of the importance and lethal effects of even mild anaemia and the benefits of its treatment in CHF and CKI. Cooperation between these specialists will allow better and much earlier treatment of the anaemia, CHF and CKI, and prevent the deterioration of all three conditions.
我们肾内科的许多贫血且患有慢性肾功能不全（CKI）的患者都有充血性心力衰竭（CHF）的迹象。贫血、CKI和CHF这三者的组合被称为心肾贫血综合征。这三种病症形成了一个恶性循环，其中每种病症都可能导致另一种病症或由另一种病症引发。贫血会加重CHF的严重程度，并与死亡率上升、住院率增加和营养不良有关。贫血还会进一步恶化肾功能，导致患者比无贫血患者更快地进展到需要透析的阶段。未得到控制的CHF会导致肾功能迅速恶化和贫血。CKI也会导致贫血，并加重CHF的严重程度，且与CHF患者的死亡率增加和住院率上升有关。如果存在贫血但未得到治疗，使用所有常规药物以公认剂量积极治疗CHF往往无法改善CHF。然而，在通过皮下注射促红细胞生成素以及在某些情况下通过静脉注射铁剂纠正贫血的研究中，通过测量左心室射血分数和最大运动时的氧利用率评估发现，心脏功能得到了改善。通过监测运动时的呼吸急促和疲劳情况发现，有症状的患者功能得到改善，住院需求以及口服和静脉利尿剂的使用明显减少。根据不同标准判断，生活质量也有所提高。在贫血未治疗时迅速下降的肾小球滤过率，在患者贫血得到治疗后趋于稳定。肾病学家需要仔细评估所有CKI患者的心脏状况，这包括进行超声心动图检查以及可能测量B型利钠肽水平。肾病学家还需要按照推荐剂量使用指定的CHF治疗药物，而心脏病学家和内科医生需要更加意识到即使是轻度贫血的重要性和致命影响以及其治疗对CHF和CKI的益处。这些专科医生之间的合作将使贫血、CHF和CKI得到更好且更早的治疗，并防止这三种病症的恶化。
