Mullens Wilfried, Abrahams Zuheir, Francis Gary S, Sokos George, Taylor David O, Starling Randall C, Young James B, Tang W H Wilson
Department of Cardiovascular Medicine, Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
Department of Cardiovascular Medicine, Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
J Am Coll Cardiol. 2009 Feb 17;53(7):589-596. doi: 10.1016/j.jacc.2008.05.068.
To determine whether venous congestion, rather than impairment of cardiac output, is primarily associated with the development of worsening renal function (WRF) in patients with advanced decompensated heart failure (ADHF).
Reduced cardiac output is traditionally believed to be the main determinant of WRF in patients with ADHF.
A total of 145 consecutive patients admitted with ADHF treated with intensive medical therapy guided by pulmonary artery catheter were studied. We defined WRF as an increase of serum creatinine >/=0.3 mg/dl during hospitalization.
In the study cohort (age 57 +/- 14 years, cardiac index 1.9 +/- 0.6 l/min/m(2), left ventricular ejection fraction 20 +/- 8%, serum creatinine 1.7 +/- 0.9 mg/dl), 58 patients (40%) developed WRF. Patients who developed WRF had a greater central venous pressure (CVP) on admission (18 +/- 7 mm Hg vs. 12 +/- 6 mm Hg, p < 0.001) and after intensive medical therapy (11 +/- 8 mm Hg vs. 8 +/- 5 mm Hg, p = 0.04). The development of WRF occurred less frequently in patients who achieved a CVP <8 mm Hg (p = 0.01). Furthermore, the ability of CVP to stratify risk for development of WRF was apparent across the spectrum of systemic blood pressure, pulmonary capillary wedge pressure, cardiac index, and estimated glomerular filtration rates.
Venous congestion is the most important hemodynamic factor driving WRF in decompensated patients with advanced heart failure.
确定在晚期失代偿性心力衰竭（ADHF）患者中，肾功能恶化（WRF）的发生主要与静脉充血相关，而非心输出量受损相关。
传统上认为心输出量降低是ADHF患者WRF的主要决定因素。
对145例连续收治的接受肺动脉导管引导下强化药物治疗的ADHF患者进行研究。我们将WRF定义为住院期间血清肌酐升高≥0.3mg/dl。
在研究队列（年龄57±14岁，心脏指数1.9±0.6l/min/m²，左心室射血分数20±8%，血清肌酐1.7±0.9mg/dl）中，58例患者（40%）发生了WRF。发生WRF的患者入院时中心静脉压（CVP）更高（18±7mmHg对12±6mmHg，p<0.001），强化药物治疗后也更高（11±8mmHg对8±5mmHg，p=0.04）。CVP<8mmHg的患者中WRF的发生率较低（p=0.01）。此外，在整个系统血压、肺毛细血管楔压、心脏指数和估计肾小球滤过率范围内，CVP对WRF发生风险进行分层的能力都很明显。
静脉充血是晚期失代偿性心力衰竭患者发生WRF的最重要血流动力学因素。
