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Chávez-Íñiguez JS, Ivey-Miranda JB, De la Vega-Mendez FM, Borges-Vela JA. How to interpret serum creatinine increases during decongestion. Front Cardiovasc Med 2023; 9:1098553. [PMID: 36684603 PMCID: PMC9846337 DOI: 10.3389/fcvm.2022.1098553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/12/2022] [Indexed: 01/06/2023] Open
Abstract
During decongestion in acute decompensated heart failure (ADHF), it is common to observe elevations in serum creatinine (sCr) values due to vascular congestion, a mechanism that involves increased central venous pressure that has a negative impact on the nephron, promoting greater absorption of water and sodium, increased interstitial pressure in an encapsulated organ developing "renal tamponade" which is one of main physiopathological mechanism associated with impaired kidney function. For the treatment of this syndrome, it is recommended to use diuretics that generate a high urinary output and natriuresis to decongest the venous system, during this process the sCr values can rise, a phenomenon that may bother some cardiologist and nephrologist, since raise the suspicion of kidney damage that could worsen the prognosis of these patients. It is recommended that increases of up to 0.5 mg/dL from baseline are acceptable, but some patients have higher increases, and we believe that an arbitrary number would be impractical for everyone. These increases in sCr may be related to changes in glomerular hemodynamics and true hypovolemia associated with decongestion, but it is unlikely that they are due to structural injury or truly hypoperfusion and may even have a positive connotation if accompanied by an effective decongestion and be associated with a better prognosis in the medium to long term with fewer major cardiovascular and renal events. In this review, we give a comprehensive point of view on the interpretation of creatinine elevation during decongestion in patients with ADHF.
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Affiliation(s)
- Jonathan S. Chávez-Íñiguez
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Juan B. Ivey-Miranda
- Heart Failure and Heart Transplant Clinic, Hospital de Cardiología, Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Frida M. De la Vega-Mendez
- Nephrology Service, Hospital Civil de Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
- University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Julian A. Borges-Vela
- Heart Failure and Heart Transplant Clinic, Hospital de Cardiología, Instituto Mexicano del Seguro Social, Mexico City, Mexico
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Pan HC, Huang TM, Sun CY, Chou NK, Tsao CH, Yeh FY, Lai TS, Chen YM, Wu VC. Predialysis serum lactate levels could predict dialysis withdrawal in Type 1 cardiorenal syndrome patients. EClinicalMedicine 2022; 44:101232. [PMID: 35059613 PMCID: PMC8760464 DOI: 10.1016/j.eclinm.2021.101232] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/23/2021] [Accepted: 11/23/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Renal replacement therapy (RRT) is an effective rescue therapy for Type 1 cardiorenal syndrome (CRS). Previous studies have demonstrated that type 1 CRS patients with severe renal dysfunction were susceptible to sepsis, and that serum lactate has been correlated with the risk of mortality in patients with sepsis. However, the association between serum lactate level and the prognosis of type 1 CRS patients requiring RRT is unknown. METHODS An inception cohort of 500 type 1 CRS patients who received RRT in a tertiary-care referral hospital in Taiwan from August 2011 to January 2018 were enrolled. The outcomes of interest were dialysis withdrawal and 90-day mortality. The results were further externally validated using sampling data of type 1 CRS patients requiring dialysis from multiple tertiary-care centers. FINDINGS The 90-day mortality rate was 52.8% and the incidence rate of dialysis withdrawal was 34.8%. Lower pre-dialysis lactate was correlated with a higher rate of dialysis withdrawal and lower rate of mortality. Generalized additive model showed that 4.2 mmol/L was an adequate cut-off value of lactate to predict mortality. Taking mortality as a competing risk, Fine-Gray subdistribution hazard analysis further indicated that a low lactate level (≦ 4.2 mmol/L) was an independent predictor for the possibility of dialysis withdrawal, as also shown in external validation. The interaction of quick Sequential Organ Failure Assessment score and lactate was associated with dialysis dependence in a disease severity-dependent manner. Furthermore, the associations between hyperlactatemia and dialysis dependence were consistent in the patients with and without sepsis. INTERPRETATION Serum lactate level is accurate and capable of forecasting the prognosis along with qSOFA severity for clinical decision-making for treating type 1 CRS patients. Further studies are needed to validate our results. FUNDING This study was supported by grants from Taiwan National Science Council [104-2314-B-002-125-MY3,106-2314-B-002-166-MY3,107-2314-B-002-026-MY3], National Taiwan University Hospital [106-FTN20,106-P02,UN106-014,106-S3582,107-S3809,107-T02,PC1246,VN109-09,109-S4634,UN109-041], Ministry of Science and Technology of the Republic of China [MOST106-2321-B-182-002,106-2314-B-182A-064,MOST107-2321-B-182-004,MOST107-2314-B-182A-138, MOST108-2321-B-182-003,MOST109-2321-B-182-001, MOST108-2314-B-182A-027], Chang Gung Memorial Hospital [CMRPG-2G0361,CMRPG-2H0161,CMRPG-2J0261, CMRPG-2K0091], and Ministry of Health and Welfare of the Republic of China [PMRPG-2L0011].
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Affiliation(s)
- Heng-Chih Pan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- Chang Gung University College of Medicine, Taoyuan, Taiwan
- Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
- Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Tao-Min Huang
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- NSARF (National Taiwan University Hospital Study Group of ARF), TAIPAI, (Taiwan Primary Aldosteronism Investigators), and CAKS (Taiwan Consortium for Acute Kidney Injury and Renal Diseases), Taipei, Taiwan
| | - Chiao-Yin Sun
- Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Nai-Kuan Chou
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chun-Hao Tsao
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Fang-Yu Yeh
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- NSARF (National Taiwan University Hospital Study Group of ARF), TAIPAI, (Taiwan Primary Aldosteronism Investigators), and CAKS (Taiwan Consortium for Acute Kidney Injury and Renal Diseases), Taipei, Taiwan
| | - Tai-Shuan Lai
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- NSARF (National Taiwan University Hospital Study Group of ARF), TAIPAI, (Taiwan Primary Aldosteronism Investigators), and CAKS (Taiwan Consortium for Acute Kidney Injury and Renal Diseases), Taipei, Taiwan
| | - Yung-Ming Chen
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Vin-Cent Wu
- Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- NSARF (National Taiwan University Hospital Study Group of ARF), TAIPAI, (Taiwan Primary Aldosteronism Investigators), and CAKS (Taiwan Consortium for Acute Kidney Injury and Renal Diseases), Taipei, Taiwan
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Xie Y, Chen J, Xu J, Shen B, Liao J, Teng J, Wang Q, Ding X. Early Goal-Directed Renal Replacement Therapy in Acute Decompensated Heart Failure Patients with Cardiorenal Syndrome. Blood Purif 2021; 51:251-259. [PMID: 34130280 DOI: 10.1159/000515826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 03/11/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The aim of this study was to clarify the efficacy of early goal-directed renal replacement therapy (GDRRT) for treatment of cardiorenal syndrome (CRS) patients after acute decompensated heart failure (ADHF). METHODS In the retrospective, observational study, we enrolled 54 patients in the early GDRRT group and 63 patients in the late GDRRT group. Baseline characteristics, clinical data at initiation renal replacement therapy time, and the clinical outcome were collected and several parameters were compared and analyzed between 2 groups. RESULTS The urine volume at GDRRT initiation time in the early group was higher than that in the late GDRRT group (1,060.3 ± 332.1 vs. 300.5 ± 148.3 mL, p < 0.001). Hemodynamic parameters such as mean artery pressure were higher (70.06 ± 32.99 vs. 54.34 ± 40.88 mm Hg, p = 0.012), the heart rate was slower (80.17 ± 15.26 vs. 99.21 ± 25.45 bpm, p = 0.002), and the diameter of inferior vena cava was narrower (22.00 ± 1.91 vs. 25.77 ± 5.5 mm, p = 0.04) in early GDRRT. Primary end point was inhospital all-cause mortality and cardiovascular mortality, which was obviously lower in the early GDRRT group (respectively 24.1 vs. 60.3%, p = 0.002 and 20.3 vs. 50.8%, p = 0.005). The second end point of kidney recovery in the early GDRRT group was much better than that in the latter GDRRT group (p = 0.018). Moreover, urine volume after GDRRT of the early group was more significant than that of the late group (1,432 ± 172 vs. 702 ± 183 mL, p = 0.005). CONCLUSION This study clarified the effectiveness of the early GDRRT strategy in ADHF patients suffered from CRS, which reduced inhospital mortality and improved the urine output and clinical kidney recovery outcome.
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Affiliation(s)
- Yeqing Xie
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiahui Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jiarui Xu
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bo Shen
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jianquan Liao
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jie Teng
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Qibing Wang
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xiaoqiang Ding
- Division of Nephrology, Zhongshan Hospital, Fudan University, Shanghai, China
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