Download PDF
Aktuelle Kardiologie 2015; 4(3): 175-180
DOI: 10.1055/s-0035-1546100
Kurzübersicht
Georg Thieme Verlag KG Stuttgart · New York

Herzinsuffizienz – medikamentöse und apparative Volumensteuerung

Congestive Heart Failure – Medical and Mechanical Decongestion
M. Koch
1   Nephrologisches Zentrum Mettmann
,
R. Westenfeld
2   Klinik für Kardiologie, Pneumologie und Angiologie, Universitätsklinikum Düsseldorf
› Author Affiliations
Further Information

Publication History

Publication Date:
15 June 2015 (online)

Also available at
    Permissions and Reprints

Zusammenfassung

Kongestion ist der häufigste Grund für eine stationäre Aufnahme einer akuten Herzinsuffizienz. Nicht ausreichende Entwässerung und Entsalzung während des stationären Aufenthalts mittels Diuretika führen häufig zur Rehospitalisation und erhöhten Mortalität. Zur Dekongestion werden Schleifendiuretika, Thiazide und Aldosteronantagonisten eingesetzt. In Abhängigkeit der Kongestion kann eine Diuretikaresistenz eintreten, die eine ausreichende Dekongestion verhindert und zu einem oligoanuren Nierenversagen führen kann. Eine rechtzeitige Ultrafiltration kann zur Dekongestion und Reduktion des Gesamtkörpernatriums führen und das Risiko einer frühen Rehospitalisation reduzieren. Über den stationären Aufenthalt hinaus kann die Peritonealdialyse als ambulantes und sicheres Verfahren für eine nachhaltige Entsalzung und Entwässerung sorgen, eine bessere Wirksamkeit der Diuretika wiederherstellen und die neurohumorale Stimulation vermindern. Prospektive randomisierte Untersuchungen müssen die offensichtlichen Vorteile dieses Verfahrens beweisen.

Abstract

Symptomatic volume overload represents a leading cause for hospital admissions in the ever-growing population of patients with congestive heart failure (CHF). Insufficient volume control and natriuresis during the index-hospitalization are associated with high readmission rates and increased mortality. Current guidelines give specific recommendations for administration of loop-diuretics as a cornerstone of volume control in CHF and recommend the addition of thiazides once diuretic resistance develops. In the case of persistent symptomatic volume overload hemofiltration may be applied for recompensation, most often applied in the setting of acute, reversible cardiogenic shock. In contrast in the setting of chronic decompensating CHF, techniques like peritoneal dialysis allow adequate symptom control and autonomous living in patients with advanced heart failure even at stages of limited prognosis.

Schlüsselwörter

Diuretikaresistenz - sequenzielle Nephronblockade - Ultrafiltration - Peritonealdialyse

Key words

diuretic resistance - Na+/K+-Cotransporter-Blocker - ultrafiltration - peritoneal dialysis
 

  • Referenzen

  • 1 McMurray JJ, Adamopoulos S, Anker SD et al. ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC. Eur Heart J 2012; 33: 1787-1847
    CrossrefPubMedGoogle Scholar
  • 2 De Bruyne LK. Mechanisms and management of diuretic resistance in congestive heart failure. Postgrad Med J 2003; 79: 268-271
    CrossrefPubMedGoogle Scholar
  • 3 Murray MD, Haag KM, Black PK et al. Variable furosemide absorption and poor predictability of response in elderly patients. Pharmacotherapy 17: 98-106
    PubMedGoogle Scholar
  • 4 Brater DC. Update in diuretic therapy: clinical pharmacology. Semin Nephrol 2011; 31: 483-494
    CrossrefPubMedGoogle Scholar
  • 5 Salvador DR, Rey NR, Ramos GC et al. Continuous infusion versus bolus injection of loop diuretics in congestive heart failure. Cochrane Database Syst Rev 2005; (3) CD003178
    PubMedGoogle Scholar
  • 6 Felker GM, Lee KL, Bull DA et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011; 364: 797-805
    CrossrefPubMedGoogle Scholar
  • 7 Sica DA, Gehr TW. Diuretic combinations in refractory oedema states: pharmacokinetic-pharmacodynamic relationships. Clin Pharmacokinet 1996; 30: 229-249
    CrossrefPubMedGoogle Scholar
  • 8 Jentzer JC, DeWald TA, Hernandez AF. Combination of loop diuretics with thiazide-type diuretics in heart failure. J Am Coll Cardiol 2010; 56: 1527-1534
    CrossrefPubMedGoogle Scholar
  • 9 Pitt B, Zannad F, Remme WJ et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med 1999; 341: 709-717
    Google Scholar
  • 10 Pitt B, Remme W, Zannad F et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med 2003; 348: 1309-1321
    Google Scholar
  • 11 Zannad F, McMurray JJ, Krum H et al. Eplerenone in patients with systolic heart failure and mild symptoms. N Engl J Med 2011; 364: 11-21
    Google Scholar
  • 12 Vardeny O, Wu DH, Desai A et al. Influence of baseline and worsening renal function on efficacy of spironolactone in patients With severe heart failure: insights from RALES (Randomized Aldactone Evaluation Study). J Am Coll Cardiol 2012; 60: 2082-2089
    CrossrefPubMedGoogle Scholar
  • 13 Lopes RJ, Lourenço AP, Mascarenhas J et al. Safety of spironolactone use in ambulatory heart failure patients. Clin Cardiol 2008; 31: 509-513
    CrossrefPubMedGoogle Scholar
  • 14 Bansal S, Lindenfeld J, Schrier RW. Sodium retention in heart failure and cirrhosis: potential role of natriuretic doses of mineralocorticoid antagonist?. Circ Heart Fail 2009; 2: 370-376
    CrossrefPubMedGoogle Scholar
  • 15 Galve E, Mallol A, Catalan R et al. Clinical and neurohumoral consequences of diuretic withdrawal in patients with chronic, stabilized heart failure and systolic dysfunction. Eur J Heart Fail 2005; 7: 892-898
    CrossrefPubMedGoogle Scholar
  • 16 Cooper HA, Dries DL, Davis CE et al. Diuretics and risk of arrhythmic death in patients with left ventricular dysfunction. Circulation 1999; 100: 1311-1315
    CrossrefPubMedGoogle Scholar
  • 17 Kazory A. Emergence of blood urea nitrogen as a biomarker of neurohormonal activation in heart failure. Am J Cardiol 2010; 106: 694-700
    CrossrefPubMedGoogle Scholar
  • 18 Damman K, Voors AA, Navis G et al. Current and novel renal biomarkers in heart failure. Heart Fail Rev 2012; 17: 241-250
    CrossrefPubMedGoogle Scholar
  • 19 Damman K, Ng Kam Chuen MJ, MacFadyen RJ et al. Volume status and diuretic therapy in systolic heart failure and the detection of early abnormalities in renal and tubular function. J Am Coll Cardiol 2011; 57: 2233-2241
    CrossrefPubMedGoogle Scholar
  • 20 Testani JM, Chen J, McCauley BD et al. Potential effects of aggressive decongestion during the treatment of decompensated heart failure on renal function and survival. Circulation 2010; 122: 265-272
    CrossrefPubMedGoogle Scholar
  • 21 Ali SS, Olinger CC, Sobotka PA et al. Loop diuretics can cause clinical natriuretic failure: a prescription for volume expansion. Congest Heart Fail 2009; 15: 1-4
    CrossrefPubMedGoogle Scholar
  • 22 Bart BA, Boyle A, Bank AJ et al. Ultrafiltration versus usual care for hospitalized patients with heart failure: the Relief for Acutely Fluid-Overloaded Patients With Decompensated Congestive Heart Failure (RAPID-CHF) trial. J Am Coll Cardiol 2005; 46: 2043-2046
    CrossrefPubMedGoogle Scholar
  • 23 Kazory A, Ross EA. Contemporary trends in the pharmacological and extracorporeal management of heart failure: a nephrologic perspective. Circulation 2008; 117: 975-983
    CrossrefPubMedGoogle Scholar
  • 24 Verbrugge FH, Dupont M, Steels P et al. The kidney in congestive heart failure: “are natriuresis, sodium, and diuretics really the good, the bad and the ugly?”. Eur J Heart Fail 2014; 16: 133-142
    CrossrefPubMedGoogle Scholar
  • 25 Costanzo MR, Guglin ME, Saltzberg MT et al. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol 2007; 49: 675-683
    CrossrefPubMedGoogle Scholar
  • 26 Giglioli C, Landi D, Cecchi E et al. Effects of ULTRAfiltration vs. DIureticS on clinical, biohumoral and haemodynamic variables in patients with deCOmpensated heart failure: the ULTRADISCO study. Eur J Heart Fail 2011; 13: 337-346
    CrossrefPubMedGoogle Scholar
  • 27 Bart BA, Goldsmith SR, Lee KL et al. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med 2012; 367: 2296-2304
    CrossrefPubMedGoogle Scholar
  • 28 Boyle A, Sobotka PA. Redefining the therapeutic objective in decompensated heart failure: hemoconcentration as a surrogate for plasma refill rate. J Card Fail 2006; 12: 247-249
    CrossrefPubMedGoogle Scholar
  • 29 Koch M, Kohnle M, Trapp R et al. Comparable outcome of acute unplanned peritoneal dialysis and haemodialysis. Nephrol Dial Transplant 2012; 27: 375-380
    CrossrefPubMedGoogle Scholar
  • 30 Núñez J, González M, Miñana G et al. Continuous ambulatory peritoneal dialysis as a therapeutic alternative in patients with advanced congestive heart failure. Eur J Heart Fail 2012; 14: 540-548
    CrossrefPubMedGoogle Scholar
  • 31 Rizkallah J, Sood MM, Reslerova M et al. Reduced hospitalizations in severe, refractory congestive heart failure with peritoneal dialysis: a consecutive case series. Clin Nephrol 2013; 80: 334-341
    CrossrefPubMedGoogle Scholar
  • 32 Courivaud C, Kazory A, Crépin T et al. Peritoneal dialysis reduces the number of hospitalization days in heart failure patients refractory to diuretics. Perit Dial Int 2014; 34: 100-108
    CrossrefPubMedGoogle Scholar
  • 33 Koch M, Haastert B, Kohnle M et al. Peritoneal dialysis relieves clinical symptoms and is well tolerated in patients with refractory heart failure and chronic kidney disease. Eur J Heart Fail 2012; 14: 530-539
    CrossrefPubMedGoogle Scholar
  • 34 Sánchez JE, Ortega T, Rodríguez C et al. Efficacy of peritoneal ultrafiltration in the treatment of refractory congestive heart failure. Nephrol Dial Transplant 2010; 25: 605-610
    CrossrefPubMedGoogle Scholar
  • 35 Damman K, Navis G, Smilde TD et al. Decreased cardiac output, venous congestion and the association with renal impairment in patients with cardiac dysfunction. Eur J Heart Fail 2007; 9: 872-878
    CrossrefPubMedGoogle Scholar
  • 36 Mullens W, Abrahams Z, Francis GS et al. Prompt reduction in intra-abdominal pressure following large-volume mechanical fluid removal improves renal insufficiency in refractory decompensated heart failure. J Card Fail 2008; 14: 508-514
    CrossrefPubMedGoogle Scholar
  • 37 Schwenger V, Remppis BA, Westenfeld R et al. Dialyse- und Ultrafiltrationsverfahren bei kardio-renalem Syndrom. Empfehlung der Arbeitsgemeinschaft „Herz – Niere“ der Deutschen Gesellschaft für Kardiologie – Herz- und Kreislaufforschung e. V. und der Deutschen Gesellschaft für Nephrologie e. V. Dtsch Med Wochenschr 2014; 139: e1-e8
    Article in Thieme ConnectPubMedGoogle Scholar
  • 38 Dharmarajan K, Hsieh AF, Lin Z et al. Diagnoses and timing of 30-day readmissions after hospitalization for heart failure, acute myocardial infarction, or pneumonia. JAMA 2013; 309: 355-363
    CrossrefPubMedGoogle Scholar
  • 39 Testani JM, Brisco MA, Chen J et al. Timing of hemoconcentration during treatment of acute decompensated heart failure and subsequent survival: importance of sustained decongestion. J Am Coll Cardiol 2013; 62: 516-524
    CrossrefPubMedGoogle Scholar