Zima Endre, Farmakis Dimitrios, Pollesello Piero, Parissis John T
Cardiac Intensive Care, Heart and Vascular Center, Semmelweis University, Budapest, Hungary.
Department of Cardiology, University of Cyprus Medical School, Nicosia, Cyprus.
Eur Heart J Suppl. 2020 May;22(Suppl D):D12-D19. doi: 10.1093/eurheartj/suaa091. Epub 2020 May 15.
Pathological interplay between the heart and kidneys is widely encountered in heart failure (HF) and is linked to worse prognosis and quality of life. Inotropes, along with diuretics and vasodilators, are a core medical response to HF but decompensated patients who need inotropic support often present with an acute worsening of renal function. The impact of inotropes on renal function is thus potentially an important influence on the choice of therapy. There is currently relatively little objective data available to guide the selection of inotrope therapy but recent direct observations on the effects of levosimendan and milrinone on glomerular filtration favour levosimendan. Other lines of evidence indicate that in acute decompensated HF levosimendan has an immediate renoprotective effect by increasing renal blood flow through preferential vasodilation of the renal afferent arterioles and increases in glomerular filtration rate: potential for renal medullary ischaemia is avoided by an offsetting increase in renal oxygen delivery. These indications of a putative reno-protective action of levosimendan support the view that this calcium-sensitizing inodilator may be preferable to dobutamine or other adrenergic inotropes in some settings by virtue of its renal effects. Additional large studies will be required, however, to clarify the renal effects of levosimendan in this and other relevant clinical situations, such as cardiac surgery.
心脏与肾脏之间的病理相互作用在心力衰竭（HF）中广泛存在，且与更差的预后和生活质量相关。正性肌力药物与利尿剂和血管扩张剂一起，是治疗HF的核心医学手段，但需要正性肌力支持的失代偿患者常常出现肾功能急性恶化。因此，正性肌力药物对肾功能的影响可能对治疗方案的选择具有重要影响。目前可用于指导正性肌力药物治疗选择的客观数据相对较少，但最近关于左西孟旦和米力农对肾小球滤过作用的直接观察结果支持左西孟旦。其他证据表明，在急性失代偿性HF中，左西孟旦通过优先扩张肾入球小动脉增加肾血流量以及增加肾小球滤过率，具有直接的肾脏保护作用：通过增加肾脏氧输送来抵消，避免了肾髓质缺血的可能性。左西孟旦假定的肾脏保护作用的这些迹象支持了这样一种观点，即在某些情况下，这种钙增敏性血管扩张剂可能因其对肾脏的作用而比多巴酚丁胺或其他肾上腺素能正性肌力药物更可取。然而，需要更多大型研究来阐明左西孟旦在这种及其他相关临床情况（如心脏手术）中的肾脏作用。
