Liang Kelly V, Williams Amy W, Greene Eddie L, Redfield Margaret M
Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN 55905, USA.
Crit Care Med. 2008 Jan;36(1 Suppl):S75-88. doi: 10.1097/01.CCM.0000296270.41256.5C.
Heart failure is one of the leading causes of hospitalizations in the United States. Concomitant and significant renal dysfunction is common in patients with heart failure. Increasingly, the syndrome of heart failure is one of cardiorenal failure, in which concomitant cardiac and renal dysfunctions exist, with each accelerating the progression of the other. One fourth of patients hospitalized for the treatment of acute decompensated heart failure will experience significant worsening of renal function, which is associated with worse outcomes. It remains unclear whether worsening renal function specifically contributes to poor outcomes or whether it is merely a marker of advanced cardiac and renal dysfunction. Diuretic resistance, with or without worsening renal function, is also common in acute decompensated heart failure, although the definition of diuretic resistance, its prevalence, and prognostic implications are less well defined. The term cardiorenal syndrome has been variably associated with cardiorenal failure, worsening renal function, and diuretic resistance but is more comprehensively defined as a state of advanced cardiorenal dysregulation manifest by one or all of these specific features. The pathophysiology of the cardiorenal syndrome is poorly understood and likely involves interrelated hemodynamic and neurohormonal mechanisms. When conventional therapy for acute decompensated heart failure fails, mechanical fluid removal via ultrafiltration, hemofiltration, or hemodialysis may be needed for refractory volume overload. While ultrafiltration can address diuretic resistance, whether ultrafiltration prevents worsening renal function or improves outcomes in patients with cardiorenal syndrome remains unclear. Evidence regarding the potential renal-preserving effects of nesiritide is mixed, and further studies on the efficacy and safety of different doses of nesiritide in heart failure therapy are warranted. Newer therapeutic agents, including vasopressin antagonists and adenosine antagonists, hold promise for the future, and clinical trials of these agents are underway.
心力衰竭是美国住院治疗的主要原因之一。心力衰竭患者常伴有严重的肾功能不全。心力衰竭综合征越来越多地成为心肾综合征，即同时存在心脏和肾脏功能障碍，且二者相互促进对方的进展。因急性失代偿性心力衰竭住院治疗的患者中有四分之一会出现肾功能显著恶化，这与更差的预后相关。肾功能恶化是否具体导致不良预后，还是仅仅是严重心脏和肾脏功能障碍的一个标志，目前尚不清楚。在急性失代偿性心力衰竭中，无论肾功能是否恶化，利尿剂抵抗都很常见，尽管利尿剂抵抗的定义、患病率及其预后意义尚未明确界定。心肾综合征这一术语与心肾衰竭、肾功能恶化和利尿剂抵抗有不同程度的关联，但更全面地定义为一种由这些特定特征中的一种或全部所表现出的严重心肾失调状态。心肾综合征的病理生理学了解甚少，可能涉及相互关联的血流动力学和神经激素机制。当急性失代偿性心力衰竭的常规治疗失败时，对于难治性容量超负荷可能需要通过超滤、血液滤过或血液透析进行机械性液体清除。虽然超滤可以解决利尿剂抵抗问题，但超滤是否能预防肾功能恶化或改善心肾综合征患者的预后仍不清楚。关于奈西立肽潜在肾脏保护作用的证据不一，因此有必要进一步研究不同剂量奈西立肽在心力衰竭治疗中的疗效和安全性。包括血管加压素拮抗剂和腺苷拮抗剂在内的新型治疗药物前景广阔，目前这些药物的临床试验正在进行中。
