De Vecchis R, Pucciarelli G, Nocerino L, Cocozza M, Setaro A, Torre G, Imperatore F
Servizio di Cardiologia, Day Hospital Elena d'Aosta, ASL 1, Napoli.
Minerva Cardioangiol. 1998 May;46(5):163-74.
We evaluated the diuretic output in patients with decompensated chronic heart failure (CHF), previously treated by i.v. infusion with dobutamine and dopamine (dob-dop) or with amrinone (amr). Our target was to identify the possible discrepancies in urinary output perhaps linked to the different type of inotropic stimulation in the two subsets.
Adjunctive therapy with dob-dop or amr was chosen because the administration of diuretics only, without cardiac support, as tested in previous hospitalizations, had been demonstrated to produce unfavourable results, mainly expressed by finding of a low output syndrome in 50% of cases or more. The administration of i.v. infusion was maintained during 17 hours (1000 min approximatively), and included infusion in separate pumps of the two amines, dobutamine at dose of 5 micrograms/kg/min and dopamine at dose of 2.8 micrograms/kg/min or, alternatively, i.v. infusion of amr, administered at dose of 7 micrograms/kg/min. Infusion volumes were similar in the two subsets. The two subsets were homogeneous relatively to renal impairment, i.e. to the parameters (urinary Na, U/P creatinine, U/P urea, urinary osmolality) we fixed as markers idoneous to demonstrate the occurrence of organic renal damage (acute tubular necrosis).
The diuresis was recovered in all 24 patients, and the urine volume resulted more pronounced in the subset attributed to the dob-dop at both the 8th and the 17th hour readings. We found no harmful alterations in HR and AP, whereas renal function parameters have been shown to enhance in both the dob-dop and amr arms. The diuretic effectiveness of the SIEV obtained by catecholamine implementation exercised a synergistic, favourable effect on diuresis, renal flow, glomerular filtration rate, and sodium post-proximal delivery. Amr resulted less effective then dob-dop simultaneous administration relatively to the diuretic effect. No remarkable differences were found in the two subsets as regards the heart rate, whereas a decrease in arterial pressure was found after amr. A persistent shift towards a condition of chronic renal failure, was identified in 4/24 patients, the two groups despite of the prolonged treatment at optimized doses: no remarkable side effects were reported.
Thus, the selective effect upon renal hemodynamics, as exercised by dob-dop infusion low doses of dop, together with the enhanced renal output due to dob, has been shown to be more effective than amr influence: thus, the catecholamine therapeutical approach has been demonstrated to possess the best effectiveness in excitation of diuresis, among the CHF oliguric patients.
我们评估了失代偿性慢性心力衰竭（CHF）患者的利尿输出情况，这些患者之前接受过静脉输注多巴酚丁胺和多巴胺（dob - dop）或氨力农（amr）治疗。我们的目标是确定尿量输出可能存在的差异，这可能与两个亚组中不同类型的正性肌力刺激有关。
选择使用dob - dop或amr进行辅助治疗，因为在之前的住院治疗中已证明，仅使用利尿剂而无心脏支持会产生不利结果，主要表现为50%或更多病例出现低输出综合征。静脉输注持续17小时（约1000分钟），包括在单独的泵中输注两种胺类药物，多巴酚丁胺剂量为5微克/千克/分钟，多巴胺剂量为2.8微克/千克/分钟，或者静脉输注氨力农，剂量为7微克/千克/分钟。两个亚组的输注量相似。两个亚组在肾功能损害方面相对同质，即相对于我们确定为证明有机肾损伤（急性肾小管坏死）发生的标志物的参数（尿钠、尿/血肌酐、尿/血尿尿素、尿渗透压）而言。
所有24例患者均恢复了利尿，在第8小时和第17小时读数时，归因于dob - dop的亚组尿量更为明显。我们未发现心率和血压有有害变化，而肾功能参数在dob - dop和amr组均有所改善。通过实施儿茶酚胺获得的SIEV的利尿效果对利尿、肾血流量、肾小球滤过率和近端钠输送后产生了协同的有利作用。相对于利尿效果，氨力农比同时给予dob - dop效果更差。两个亚组在心率方面未发现显著差异，而在使用氨力农后发现动脉压下降。在4/24例患者中发现持续向慢性肾衰竭状态转变，尽管两组均以优化剂量进行了长时间治疗：未报告明显的副作用。
因此，低剂量多巴胺的dob - dop输注对肾血流动力学的选择性作用，以及多巴酚丁胺导致的肾输出增加，已被证明比氨力农的影响更有效：因此，在CHF少尿患者中，儿茶酚胺治疗方法已被证明在激发利尿方面具有最佳效果。
