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Kobayashi M, Stienen S, Ter Maaten JM, Dickstein K, Samani NJ, Lang CC, Ng LL, Anker SD, Metra M, Preud'homme G, Duarte K, Lamiral Z, Girerd N, Rossignol P, van Veldhuisen DJ, Voors AA, Zannad F, Ferreira JP. Clinical determinants and prognostic implications of renin and aldosterone in patients with symptomatic heart failure. ESC Heart Fail 2020; 7:953-963. [PMID: 32167681 PMCID: PMC7261568 DOI: 10.1002/ehf2.12634] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/26/2019] [Accepted: 01/14/2020] [Indexed: 12/17/2022] Open
Abstract
Aims Activation of the renin–angiotensin–aldosterone system plays an important role in the pathophysiology of heart failure (HF) and has been associated with poor prognosis. There are limited data on the associations of renin and aldosterone levels with clinical profiles, treatment response, and study outcomes in patients with HF. Methods and results We analysed 2,039 patients with available baseline renin and aldosterone levels in BIOSTAT‐CHF (a systems BIOlogy study to Tailored Treatment in Chronic Heart Failure). The primary outcome was the composite of all‐cause mortality or HF hospitalization. We also investigated changes in renin and aldosterone levels after administration of mineralocorticoid receptor antagonists (MRAs) in a subset of the EPHESUS trial and in an acute HF cohort (PORTO). In BIOSTAT‐CHF study, median renin and aldosterone levels were 85.3 (percentile25–75 = 28–247) μIU/mL and 9.4 (percentile25–75 = 4.4–19.8) ng/dL, respectively. Prior HF admission, lower blood pressure, sodium, poorer renal function, and MRA treatment were associated with higher renin and aldosterone. Higher renin was associated with an increased rate of the primary outcome [highest vs. lowest renin tertile: adjusted‐HR (95% CI) = 1.47 (1.16–1.86), P = 0.002], whereas higher aldosterone was not [highest vs. lowest aldosterone tertile: adjusted‐HR (95% CI) = 1.16 (0.93–1.44), P = 0.19]. Renin and/or aldosterone did not improve the BIOSTAT‐CHF prognostic models. The rise in aldosterone with the use of MRAs was observed in EPHESUS and PORTO studies. Conclusions Circulating levels of renin and aldosterone were associated with both the disease severity and use of MRAs. By reflecting both the disease and its treatments, the prognostic discrimination of these biomarkers was poor. Our data suggest that the “point” measurement of renin and aldosterone in HF is of limited clinical utility.
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Affiliation(s)
- Masatake Kobayashi
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Susan Stienen
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kenneth Dickstein
- Department of Internal Medicine, University of Bergen, Bergen, Norway.,Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
| | - Nilesh J Samani
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Ninewells Hospital & Medical School, Dundee, UK
| | - Leong L Ng
- Department of Cardiovascular Sciences, University of Leicester, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin, Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin Berlin, Germany
| | - Macro Metra
- Department of Cardiology, University and Civil hospitals of Brescia, Brescia, Italy
| | - Gregoire Preud'homme
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Kevin Duarte
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Zohra Lamiral
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
| | - João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Université de Lorraine, Nancy, France
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Abstract
Cardiorenal syndrome is a complex interplay of dysregulated heart and kidney interaction that leads to multiorgan system dysfunction, which is not an uncommon occurrence in the setting of right heart failure. The traditional concept of impaired perfusion and forward flow recently has been modified to include the recognition of systemic venous congestion as a contributor, with direct and indirect mechanisms, including elevated renal venous pressure, reduced renal perfusion pressure, increased renal interstitial pressure, tubular dysfunction, splanchnic congestion, and neurohormonal and inflammatory activation. Treatment options beyond diuretics and vasoactive drugs remain limited and lack supportive evidence.
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Affiliation(s)
- Thida Tabucanon
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
| | - Wai Hong Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA; Department of Cardiovascular Medicine, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA.
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Gronda E, Francis D, Zannad F, Hamm C, Brugada J, Vanoli E. Baroreflex activation therapy: a new approach to the management of advanced heart failure with reduced ejection fraction. J Cardiovasc Med (Hagerstown) 2018; 18:641-649. [PMID: 28737621 PMCID: PMC5555968 DOI: 10.2459/jcm.0000000000000544] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Chronic heart failure is a common clinical condition characterized by persistent excessive sympathetic nervous system activation. The derangement of the sympathetic activity has relevant implications for disease progression and patient survival. Aiming to positively impact patient outcome, autonomic nervous system modulatory therapies have been developed and tested in animal and clinical studies. As a general gross assumption, direct vagal stimulation and baroreflex activation are considered equivalent. This assumption does not take into account the fact that direct cervical vagal nerve stimulation involves activation of both afferent and efferent fibers innervating not only the heart, but the entire visceral system, leading to undesired responses to and from this compartment. The different action of baroreflex activation is based on generating a centrally mediated reduction of sympathetic outflow and increasing parasympathetic activity to the heart via a physiological reflex pathway. Thus, baroreflex activation rebalances the unbalanced autonomic nervous system via a specific path. Independent and complementary investigations have shown that sympathetic nerve activity can be rebalanced via control of the arterial baroreflex in heart failure patients. Results from recent pioneering research studies support the hypothesis that baroreflex activation can add significant therapeutic benefit on top of guideline-directed medical therapy in patients with advanced heart failure. In the present review, baroreflex activation therapy results are discussed, focusing on critical aspects like patient selection rationale to support clinician orientation in opting for baroreflex activation therapy when, on top of current guideline-directed medical treatment, other therapies are to be considered.
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Affiliation(s)
- Edoardo Gronda
- aCardiovascular Department, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy bNational Heart and Lung Institute, Imperial College London, London, UK cUnité 1116, Department of Cardiology, Centre d'Investigations Cliniques, INSERM, CHU de Nancy, Université de Lorraine, Nancy, France dKerckhoff Heart Center, Bad Nauheim Medical Clinic I, University of Giessen, Giessen, Germany eCardiovascular Institute, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain fDepartment of Molecular Medicine, University of Pavia, Pavia, Italy
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5
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Hering D, Winklewski PJ. R1 autonomic nervous system in acute kidney injury. Clin Exp Pharmacol Physiol 2017; 44:162-171. [DOI: 10.1111/1440-1681.12694] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 10/17/2016] [Accepted: 10/29/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Dagmara Hering
- Dobney Hypertension Centre; School of Medicine and Pharmacology; Royal Perth Hospital Unit; The University of Western Australia; Perth WA Australia
| | - Pawel J Winklewski
- Institute of Human Physiology; Medical University of Gdansk; Gdansk Poland
- Department of Clinical Sciences; Institute of Health Sciences; Pomeranian University of Slupsk; Slupsk Poland
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Iacoviello M, Doronzo A, Paradies V, Antoncecchi V, Monitillo F, Citarelli G, Leone M, Puzzovivo A, Gesualdo L, Ciccone MM. The independent association between altered renal arterial resistance and loop diuretic dose in chronic heart failure outpatients. IJC HEART & VASCULATURE 2015; 7:119-123. [PMID: 28785659 PMCID: PMC5497238 DOI: 10.1016/j.ijcha.2015.03.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2014] [Revised: 03/17/2015] [Accepted: 03/18/2015] [Indexed: 01/18/2023]
Abstract
Background In chronic heart failure (CHF) patients there is a wide variability in the minimal effective diuretic dose. The aim of this study is to evaluate whether renal resistance index (RRI) is associated to baseline diuretic dose and the changes at one year. Methods and results 250 outpatients in a stable condition and in conventional therapy were enrolled. Baseline RRI was calculated by renal arterial Doppler. The total daily dose of loop diuretics was assessed at baseline and after one year. High diuretic dose (HDD) was defined as a daily furosemide equivalent dose > 100 mg. RRI was independently associated with baseline HDD at univariate (OR 1.39; 95% CI: 1.233–1.58; p < 0.001) and multivariate analysis (OR 1.27; 95% CI: 1.09–1.49; p: 0.002) after correction for other univariate predictors (age, NYHA class, left ventricular ejection fraction, tricuspid annulus peak of systolic excursion, NT-proBNP, glomerular filtration rate by EPI formula and central venous pressure). Moreover, baseline RRI was independently associated to one year stable increase in loop diuretic dose at univariate and multivariate regression analyses. Conclusions RRI is independently associated with high dose loop diuretics and their increase during a mid-term follow-up thus suggesting its usefulness in detecting an altered diuretic response in CHF outpatients.
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Affiliation(s)
- Massimo Iacoviello
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Annalisa Doronzo
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Valeria Paradies
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Valeria Antoncecchi
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Francesco Monitillo
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Gaetano Citarelli
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Marta Leone
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Agata Puzzovivo
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Loreto Gesualdo
- Nephrology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
| | - Marco Matteo Ciccone
- Cardiology Unit, Department of Emergency and Organ Transplantation, University of Bari, Bari, Italy
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Calzavacca P, May CN, Bellomo R. Glomerular haemodynamics, the renal sympathetic nervous system and sepsis-induced acute kidney injury. Nephrol Dial Transplant 2014; 29:2178-2184. [DOI: 10.1093/ndt/gfu052] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Effects of renal denervation on regional hemodynamics and kidney function in experimental hyperdynamic sepsis. Crit Care Med 2014; 42:e401-9. [PMID: 24670939 DOI: 10.1097/ccm.0000000000000302] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the influence of the renal sympathetic nerves on the pathogenesis of septic acute kidney injury. DESIGN Interventional control study to determine the effects of renal denervation in ovine hyperdynamic sepsis. SETTING Research Institute. SUBJECTS Twenty-four adult Merino ewes. INTERVENTIONS The effects of infusion of angiotensin II and norepinephrine and induction of hyperdynamic sepsis by administration of live Escherichia coli were examined in control sheep and in sheep at 2 weeks after bilateral renal denervation (n = 10/group). MEASUREMENTS AND MAIN RESULTS Systemic hemodynamics and renal function were measured in conscious sheep instrumented with flow probes on the pulmonary and renal arteries. Angiotensin II, but not norepinephrine, had a greater pressor effect in denervated animals. Sepsis increased cardiac output by 60%, renal blood flow by 35%, and arterial lactate by approximately four-fold. The denervated compared with the control group had a greater degree of hypotension during sepsis (68 vs 81 mm Hg; p = 0.003) and a reduction in the early polyuric response (from 496 to 160 mL at 2-8 hr of sepsis; p < 0.001). Creatinine clearance decreased similarly in both groups. CONCLUSIONS In experimental hyperdynamic sepsis, renal denervation was associated with greater hypotension and a loss of the initial diuresis, but no significant change in creatinine clearance. In sepsis, the renal nerves help support arterial pressure and determine the initial diuretic response, but septic acute kidney injury developed similarly in the innervated and denervated groups.
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Khundmiri SJ. Advances in understanding the role of cardiac glycosides in control of sodium transport in renal tubules. J Endocrinol 2014; 222:R11-24. [PMID: 24781255 DOI: 10.1530/joe-13-0613] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Cardiotonic steroids have been used for the past 200 years in the treatment of congestive heart failure. As specific inhibitors of membrane-bound Na(+)/K(+) ATPase, they enhance cardiac contractility through increasing myocardial cell calcium concentration in response to the resulting increase in intracellular Na concentration. The half-minimal concentrations of cardiotonic steroids required to inhibit Na(+)/K(+) ATPase range from nanomolar to micromolar concentrations. In contrast, the circulating levels of cardiotonic steroids under physiological conditions are in the low picomolar concentration range in healthy subjects, increasing to high picomolar levels under pathophysiological conditions including chronic kidney disease and heart failure. Little is known about the physiological function of low picomolar concentrations of cardiotonic steroids. Recent studies have indicated that physiological concentrations of cardiotonic steroids acutely stimulate the activity of Na(+)/K(+) ATPase and activate an intracellular signaling pathway that regulates a variety of intracellular functions including cell growth and hypertrophy. The effects of circulating cardiotonic steroids on renal salt handling and total body sodium homeostasis are unknown. This review will focus on the role of low picomolar concentrations of cardiotonic steroids in renal Na(+)/K(+) ATPase activity, cell signaling, and blood pressure regulation.
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Affiliation(s)
- Syed Jalal Khundmiri
- Division of Nephrology and HypertensionDepartment of MedicineDepartment of Physiology and BiophysicsUniversity of Louisville, 570 S. Preston Street, Louisville, Kentucky 40202, USADivision of Nephrology and HypertensionDepartment of MedicineDepartment of Physiology and BiophysicsUniversity of Louisville, 570 S. Preston Street, Louisville, Kentucky 40202, USA
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Helal I, McFann K, Reed B, Yan XD, Schrier RW, Fick-Brosnahan GM. Serum uric acid, kidney volume and progression in autosomal-dominant polycystic kidney disease. Nephrol Dial Transplant 2012; 28:380-5. [PMID: 23222419 DOI: 10.1093/ndt/gfs417] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hyperuricemia has been implicated in the development and progression of chronic kidney disease, both in animal experiments and in clinical studies. As a potentially modifiable risk factor, we examined whether serum uric acid levels correlate with early hypertension, kidney volume and progression to end-stage renal disease (ESRD) in autosomal-dominant polycystic kidney disease (ADPKD). METHODS Retrospective analysis of a prospective observational study of the natural history of ADPKD, conducted at the University of Colorado between 1985 and 2005. Included are 680 ADPKD adults who provided data on blood pressure, renal volume, renal function, uric acid, age at the onset of ESRD or last known age without ESRD. Serum uric acid levels were examined as a continuous variable and as gender-specific quartiles. The main outcome of interest was age at the onset of ESRD; secondary outcomes were hypertension onset before age 30 years and total kidney volume (TKV) at the study visit. RESULTS Subjects with early-onset hypertension had higher age-adjusted serum uric acid levels than those with no or late-onset hypertension despite similar creatinine clearance. After adjusting for age, gender and creatinine clearance, there was a 5.8% increase in TKV and 4.1% increase in TKV/body surface area for every 1 mg/dL increase in uric acid (P = 0.007). The multivariate-adjusted Cox regression demonstrated a greater hazard ratio for ESRD for subjects in the 4th and 3rd quartiles of uric acid compared with the 1st [4.8 (2.6-8.9; P < 0.001) and 2.9 (1.6-5.3; P < 0.001)]. CONCLUSIONS Higher serum uric acid levels are associated with earlier onset of hypertension, larger kidney volume and increased hazard for ESRD in ADPKD independent of gender, body mass index and renal function at the study visit. Randomized interventional studies will be necessary to examine whether treating hyperuricemia has a protective role in ADPKD.
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Affiliation(s)
- Imed Helal
- Division of Renal Diseases and Hypertension, University of Colorado Denver, Aurora, CO, USA
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11
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Abstract
Sodium and water retention in cardiac failure and cirrhosis is pivotal in the morbidity and mortality of patients with these disorders. Moreover, the pathophysiology of these edematous disorders is quite similar. Both disorders have activation of the renin-angiotensin-aldosterone system, increased sympathetic activity, and nonosmotic stimulation of arginine vasopressin, which is initiated by unloading of the arterial baroreceptors; this occurs secondary to diminished cardiac output with heart failure and primary systemic arterial vasodilation with cirrhosis. With this common pathophysiology causing pulmonary congestion, ascites, and peripheral edema, diuretics are pivotal in the therapy of patients with heart failure and cirrhosis. Advanced cardiac failure and cirrhosis both show secondary hyperaldosteronism and impaired renal escape from the sodium-retaining effect of aldosterone. However, currently there are contradictory uses of mineralocorticoid-receptor antagonists in cardiac failure (non-natriuretic doses) versus cirrhosis (natriuretic doses). This disparity relates to the greater potential of hyperkalemia in cardiac failure patients receiving inhibitors of the renin-angiotensin-aldosterone system. This review discusses the beneficial and potentially deleterious effects of diuretic use in patients with cardiac failure and cirrhosis.
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Affiliation(s)
- Robert W Schrier
- Division of Renal Diseases and Hypertension, University of Colorado Denver School of Medicine, Aurora, CO 80045, USA.
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Blood urea nitrogen a marker for adverse effects of loop diuretics? J Am Coll Cardiol 2011; 58:383-5. [PMID: 21757115 DOI: 10.1016/j.jacc.2011.01.054] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2011] [Accepted: 01/22/2011] [Indexed: 11/20/2022]
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Sarraf M, Masoumi A, Schrier RW. Cardiorenal syndrome in acute decompensated heart failure. Clin J Am Soc Nephrol 2009; 4:2013-26. [PMID: 19965544 DOI: 10.2215/cjn.03150509] [Citation(s) in RCA: 120] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Renal dysfunction is highly prevalent in patients with heart failure. Furthermore, worsening renal function in patients with acute decompensated heart failure (ADHF), the so-called cardiorenal syndrome, impacts short and long-term morbidity and mortality. In recent years, more evidence has surfaced from clinical trials and heart failure registries that a complex cross-talk between the kidney and heart in patients with ADHF exists. Meanwhile, management of patients presenting with ADHF and concomitant renal dysfunction continues to be challenging. Therefore, understanding the interaction of the heart and kidneys is pivotal in tailoring therapy of these patients. We have extensively reviewed the pathophysiology of ADHF, the role of neurohoromones as well as other biomarkers and predictors of mortality in these patients based on the current evidence. Moreover, we have discussed the current and future pharmacologic and non-pharmacologic therapies for treatment of this deadly disease. The strength of the evidence is limited, however, due to a paucity of randomized controlled trials in this patient population. What is evident from current national statistics; however, are the poor results in treating the congestion of ADHF. In this regard, the role of secondary hyperaldosteronism is discussed in the diuretic section as well as diuretic resistance in ADHF. In conclusion, since renal function is the single most important prognostic factor in the outcome of patients with ADHF, a better understanding of the pathophysiology of the cardiorenal syndrome is needed to target therapy and ultimately improve the mortality of patients with ADHF.
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Affiliation(s)
- Mohammad Sarraf
- Division of Renal Diseases & Hypertension, University of Colorado Denver, Aurora, CO 80045, USA
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Abstract
Patients with cirrhosis and heart failure (HF) share the pathophysiology of decreased effective arterial blood volume because of splanchnic vasodilatation in cirrhosis and decreased cardiac output in HF, with resultant stimulation of the renin-angiotensin-aldosterone system. Hyperaldosteronism plays a major role in the pathogenesis of ascites and contributes to resistance to loop diuretics. Therefore, the use of high doses of aldosterone antagonist (spironolactone up to 400 mg/day) is the main therapy to produce a negative sodium balance in cirrhotic patients with ascites. Hyperaldosteronism also has increasingly been recognized as a risk factor for myocardial and vascular fibrosis. Therefore, low-dose aldosterone antagonists are being used in patients with HF for cardioprotective action. However, the doses (25 to 50 mg/day) at which they are being used in cardiac patients as reported in the Randomized Aldactone Evaluation Study are not natriuretic. It is likely, therefore, that the mortality benefit relates primarily from their effect on cardiac and vascular fibrosis. Resistance to commonly used loop diuretics is frequently present in patients with advanced HF. In patients with decompensated HF with volume overload who are loop diuretic resistant, ultrafiltration may be the only available option. This is, however, an invasive procedure. For these patients, natriuretic doses of aldosterone antagonists (spironolactone >50 mg/day) may be a potential option. The competitive natriuretic response of aldosterone antagonists is related to activity of the renin-angiotensin-aldosterone system: the higher the renin-angiotensin-aldosterone system activity, the higher the dose of aldosterone antagonist required to produce natriuresis. This article will discuss the potential use of natriuretic doses of aldosterone antagonists in patients with HF, including the potential side effect of hyperkalemia.
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Affiliation(s)
- Shweta Bansal
- From the Department of Medicine, Division of Renal Diseases and Hypertension and the Division of Cardiology, University of Colorado Denver, Aurora, Colorado
| | - JoAnn Lindenfeld
- From the Department of Medicine, Division of Renal Diseases and Hypertension and the Division of Cardiology, University of Colorado Denver, Aurora, Colorado
| | - Robert W. Schrier
- From the Department of Medicine, Division of Renal Diseases and Hypertension and the Division of Cardiology, University of Colorado Denver, Aurora, Colorado
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Abstract
The incidence and prevalence of heart failure is on the rise. It has become the single most expensive health care item in the United States and the number one discharge diagnosis in the elderly. The goals of therapy include both prevention and treatment of heart failure. In recent years research studies and randomized clinical trials have revolutionized the understanding of the pathophysiology and treatment of this disease. This article focuses on the medical management of chronic systolic heart failure based on the pathophysiology of the disease. Systolic heart failure is characterized by a decrease in left ventricular function and cardiac output, which results in activation of several neurohormonal compensatory systems. The long term effects of this neurohormonal activation leads to further deterioration of cardiac function. The use of hydralazine and nitrates to reduce the systemic vascular resistance was the first to show an improvement in mortality and morbidity. Then angiotensin converting enzyme inhibitors, by inhibiting the renin angiotensin system, demonstrated a greater improvement in mortality and morbidity. More recently the inhibition of the sympathetic stimulation with beta-blockers has been shown to have an additive effect on morbidity and mortality in combination with angiotensin-converting enzyme inhibitors. Digoxin and diuretics remain important for improving symptoms and decreasing hospitalizations but have not been shown to decrease mortality. The most recent advance in the treatment of cardiac failure is the demonstration that the aldosterone antagonists, spironolactone decreases morbidity and mortality.
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Affiliation(s)
- R W Schrier
- Department of Medicine, University of Colorado School of Medicine, Denver, CO 80262 USA
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Leach CS. A review of the consequences of fluid and electrolyte shifts in weightlessness. ACTA ASTRONAUTICA 1979; 6:1123-1135. [PMID: 11883481 DOI: 10.1016/0094-5765(79)90060-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
This review describes the renal-endocrine mechanisms related to the early losses of fluid-electrolytes from the body during weightlessness as well as their contribution to longer term adaptation of fluid-electrolyte balance. The hypotheses presented were generated by a systematic analysis of body fluid and renal dynamics observed under conditions of actual and simulated spaceflight. These have increased our understanding of the effects of acute headward fluid shifts on renal excretion, the factors promoting excess sodium excretion and the regulation of extracellular fluid composition.
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Affiliation(s)
- C S Leach
- Biomedical Laboratories Branch, NASA-Johnson Space Center, Houston, TX 77058, USA
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Uttley WS, Habel AH. Fluid and electrolyte metabolism in the newborn infant. CLINICS IN ENDOCRINOLOGY AND METABOLISM 1976; 5:3-30. [PMID: 776460 DOI: 10.1016/s0300-595x(76)80006-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
This chapter has sought to gather together the background information on systems controlling homoeostasis of salt and water and their clinical derangement. The temptation to adopt an all-embracing approach to the management of these problems is strong but such an approach is difficult to achieve and indeed dangerous. The circumstances of each sick infant are unique and plans for treatment must be individually tailored and flexible, dependent upon clinical and biochemical progress. Future developments in this field are likely to involve further understanding of renal and hormonal control of fluid and electrolyte and it might be expected that as new methods of management emerge they will be accompanied by their own peculiar risks of inducing secondary homoeostatic disturbances. With regard to infant feeding each advance appears to underline the desirability of breast feeding and support current moves toward provision of low solute feeds for those who are artificially fed. Paediatricians should be vocal in their advocation of breast feeding and ensure that the major principles of salt and water handling are understood by all who work with small infants. An extra scoop of powdered milk can be more of a poison than a food.
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Gonick HC, Saldanha LF. A natriuretic principle derived from kidney tissue of volume-expanded rats;. J Clin Invest 1975; 56:247-55. [PMID: 1150868 PMCID: PMC436581 DOI: 10.1172/jci108087] [Citation(s) in RCA: 37] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Homogenates of kidneys from hydropenic and volume-expanded rats were subjected to gel filtration with Sephadex G-25. A fraction of the eluate coincident with the fourth UV peak was injected into the aorta of rats with one kidney excluded. A fraction eluting before the albumin peak was utilized as a control. Significant natriuresis and diuresis were observed after infusion of the fraction obtained from volume-expanded kidneys but not after infusion of the fraction from hydropenic kidneys or the control fraction. The natriuresis occurred in in the absence of changes in mean blood pressure, hematocrit, plasma sodium and potassium, glomerular filtration rate, and potassium excretion. The response was apparent immediately after infusion and persisted for up to 150 min. These results verify the existence of a low molecular weight natriuretic substance which may be preferentially bound to the kidney after its volume-stimulated release into the circulation.
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Barajas L, Müller J. The innervation of the juxtaglomerular apparatus and surrounding tubules: a quantitative analysis by serial section electron microscopy. JOURNAL OF ULTRASTRUCTURE RESEARCH 1973; 43:107-32. [PMID: 4349957 DOI: 10.1016/s0022-5320(73)90073-7] [Citation(s) in RCA: 116] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Müller J, Barajas L. Electron microscopic and histochemical evidence for a tubular innervation in the renal cortex of the monkey. JOURNAL OF ULTRASTRUCTURE RESEARCH 1972; 41:533-49. [PMID: 4629670 DOI: 10.1016/s0022-5320(72)90054-8] [Citation(s) in RCA: 93] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Thames MD, Schrier RW, De Wardener HE. Intrathoracic volume receptors. N Engl J Med 1972; 286:545-6. [PMID: 5059272 DOI: 10.1056/nejm197203092861019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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