[Show abstract][Hide abstract] ABSTRACT: The current models of cardiorenal syndrome (CRS) are mainly based on a cardiocentric approach; they assume that worsening renal function is an adverse consequence of the decline in cardiac function rather than a separate and independent pathologic phenomenon. If this assumption were true, then mechanical extraction of fluid (i.e., ultrafiltration therapy) would be expected to portend positive impact on renal hemodynamics and function through improvement in cardio-circulatory physiology and reduction in neurohormonal activation. However, currently available ultrafiltration trials, whether in acute heart failure (AHF) or in CRS, have so far failed to show any improvement in renal function; they have reported no impact or even observed adverse renal outcomes in this setting. Moreover, the presence or absence of renal dysfunction seems to affect the overall safety and efficacy of ultrafiltration therapy in AHF. This manuscript briefly reviews cardiorenal physiology in AHF and concludes that therapeutic options for CRS should not only target cardio-circulatory status of the patients, but they need to also have the ability of addressing the adverse homeostatic consequences of the associated decline in renal function. Peritoneal dialysis (PD) can be such an option for the chronic cases of CRS as it has been shown to provide efficient intracorporeal ultrafiltration and sodium extraction in volume overloaded patients while concurrently correcting the metabolic consequences of diminished renal function. Currently available trials on PD in heart failure have shown the safety and efficacy of this therapeutic modality for patients with chronic CRS and suggest that it could represent a pathophysiologically and conceptually relevant option in this setting.
Preview · Article · Jul 2015 · World Journal of Cardiology (WJC)
[Show abstract][Hide abstract] ABSTRACT: To provide an overview on the most recent evidence for the use of extracorporeal and peritoneal ultrafiltration in heart failure, focusing on the major publications from the last few years.
There have been several studies investigating the possible use of extracorporeal and peritoneal ultrafiltration in the management of acute and chronic heart failure. These trials have investigated the potential benefits and advantages of ultrafiltration over conventional medical therapy, in terms of clinical outcomes.
Although ultrafiltration remains an extremely appealing therapeutic option for patients with heart failure and congestion, with several theoretical beneficial effects, some of the most recent studies have reported inconsistent findings. Differences in the selection of the study population, heterogeneity of the indications for use of ultrafiltration, variation in the ultrafiltration protocols, and high variability in the pharmacologic therapy used for the control group could explain some of these conflicting findings.
No preview · Article · Jan 2015 · Current Opinion in Cardiology
[Show abstract][Hide abstract] ABSTRACT: Simultaneous dysfunction of the heart and the kidney represents a distinct spectrum of disease states composed of complex clinical scenarios with adverse outcomes. Worsening renal function (WRF) in the setting of acute decompensated heart failure (ADHF) is one such clinical setup for which the underlying mechanisms are poorly understood. Apparent discrepancies exist between the emerging data on the cardiorenal interactions of patients with ADHF and contemporary concepts such as the low forward flow or the high backward pressure hypotheses. The findings of the recent retrospective studies also suggest that apparent "improvement in renal function" might be yet another risk factor for untoward outcomes in this patient population, further challenging our current understanding of the cardiorenal interactions. Besides, these data do not seem to fully support our conventional thinking about other aspects of these interactions such as the independent adverse impact of WRF on the outcomes of patients with ADHF, pointing to congestion as a possibly overlooked factor. In this article we provide an overview of these emerging controversial issues with the goal of identifying the areas where clinical research could be most helpful as it is of paramount importance to characterize the pathways leading to WRF in ADHF in order to develop a mechanistically-relevant management strategy. While the paucity of data coupled with the complexity of this field precludes any firm conclusion, these discussions are meant to prompt clinicians and researchers to revisit a number of long-believed concepts surrounding the cardiorenal interactions in ADHF.
No preview · Article · Sep 2014 · Journal of Cardiac Failure
[Show abstract][Hide abstract] ABSTRACT: Despite major advances in pharmacological therapy and cardiac devices, heart failure patients continue to be frequently (re-)hospitalized with signs and symptoms of fluid overload. Diuretics improve the symptoms of fluid overload, but their effectiveness is reduced by a number of factors including excess salt intake, underlying chronic kidney disease, renal adaptation to their actions and neurohormonal activation. Ultrafiltration (UF) is a mechanical method of fluid removal with several potential advantages over diuretic-based conventional therapies: several recent studies have demonstrated favorable clinical response to UF therapy. Such studies have shown that removal of large amounts of isotonic fluid, in addition to relieving symptoms of congestion, can improve exercise capacity, reduce cardiac filling pressures, restore diuretic responsiveness, and portend a favorable effect on cardio-pulmonary, cardiorenal interactions, and neurohormonal hyperactivation. However, despite these proposed benefits, so far, no clinical study has yet been carried out to explore the impact of UF therapy on hard clinical endpoints such as long-term mortality. In this article, we review a number of mechanistic aspects of UF therapy, with particular emphasis on cardio-pulmonary and cardiorenal interactions, and revisit the results of more recent clinical trials in order to highlight the characteristics that can help identify patients who are more likely to benefit from this therapeutic modality.
[Show abstract][Hide abstract] ABSTRACT: Kidney International aims to inform the renal researcher and practicing nephrologists on all aspects of renal research. Clinical and basic renal research, commentaries, The Renal Consult, Nephrology sans Frontieres, minireviews, reviews, Nephrology Images, Journal Club. Published weekly online and twice a month in print.
No preview · Article · Feb 2014 · Kidney International
[Show abstract][Hide abstract] ABSTRACT: This is the report of a case of methotrexate nephrotoxicity for which glucarpidase was used. We use the case to review a number of teaching points related to this new treatment option.
No preview · Article · Dec 2013 · Journal of Oncology Pharmacy Practice
[Show abstract][Hide abstract] ABSTRACT: While fibromuscular dysplasia (FMD) is an established cause of secondary hypertension, its association with renal infarction
is less well recognized. We report a middle-aged man who presented with complaints of loin pain and severe hypertension. Computed
tomography angiography of the abdomen revealed bilateral renal infarction with multiple short-segment arterial dissection
compatible with FMD in the absence of systemic vasculitis and other risk factors for thromboembolic events. Bilateral renal
infarction complicating FMD is extremely rare and has so far been reported only in a handful of cases. Physicians encountering
cases of otherwise unexplained renal infarction/ischemia need to be aware of this complication.
[Show abstract][Hide abstract] ABSTRACT: Studies exploring the impact of overweight on mortality have reported controversial results in dialysis patients; some have found overweight to increase mortality, whereas others suggest that it offers a survival advantage. We conducted a prospective study to evaluate the impact of overweight on atherosclerotic events (AE) in dialysis patients with special respect to the malnutrition/inflammation complex syndrome (MICS).
Five hundred and forty-one hemodialysis patients from 11 dialysis centers in France were included. A number of baseline parameters including traditional and non-traditional cardiovascular (CV) risk factors were measured and the cohort was followed prospectively.
Over a mean follow-up of 39 months, 207 patients (38.3%) experienced an AE. Overweight, defined by a body mass index greater than 25 kg/m(2), was associated with increased risk of AEs [RR: 1.68 (CI: 1.11-3.56)], and CV mortality [RR: 1.51 (CI: 1.07-2.13)]. The effect of overweight was different in patients with and without MICS. Age, diabetes, a previous history of CV disease, high serum levels of homocysteine and MICS were also associated with an increased risk of AEs.
Similar to the general population, overweight contributes to an increased risk for AEs and CV mortality in hemodialysis patients. The presence or absence of MICS can modify the impact of overweight on development of AEs and mortality in this population.
Preview · Article · Nov 2013 · Nephrology Dialysis Transplantation
[Show abstract][Hide abstract] ABSTRACT: Previous small studies have reported favorable results of peritoneal dialysis (PD) in the setting of chronic refractory heart failure (CRHF). We evaluated the impact of PD in a larger cohort of patients with CHRF where end-stage renal disease was excluded.
All patients who received PD therapy for CRHF between January 1995 and December 2010 in two medical centers in France were included in this retrospective study. Baseline characteristics were compared with clinical parameters during the first year after initiation of PD. Mortality, safety, and sustainability of PD were also analyzed.
The 126 patients included had a mean age of 72 ± 11 years and an estimated glomerular filtration rate of 33.5 ± 15.1 mL/min/1.73 m2. Mean time on PD was 16±16.6 months. During the first year, patients with a left ventricular ejection fraction (LVEF) of 30% or less experienced improvement in cardiac function (30% ± 10% vs 20% ± 6%, p < 0.0001). We observed a significant reduction in the number of days of hospitalization for acute decompensated heart failure after PD initiation (3.3 ± 2.6 days/patient-month vs 0.3 ± 0.5 days/patient-month, p < 0.0001). One-year mortality was 42%.
In CRHF, PD significantly reduces the number of days of hospitalization for acute heart failure. Improved LVEF may have led to the comparatively good 1-year survival in this cohort.
[Show abstract][Hide abstract] ABSTRACT: Heart failure is the leading cause of hospitalization in older patients and is considered a public health problem with a significant financial burden on the health care system. Management of volume status in patients with heart failure remains a desirable but challenging clinical goal. Achievement and maintenance of optimal volume status mainly through the use of diuretics requires deep understanding of the pathophysiology of salt and water homeostasis. In that there is often a balance between beneficial and maladaptive mechanisms and neurohumoral responses, this physiologic approach also provides insight into the rationale for combining therapies. Multi-agent strategies may thus maximize their effectiveness while minimizing adverse effects and tolerance, although adverse renal outcomes and diuretic resistance could preclude aggressive use of diuretics in certain cases. In this chapter, we first review commonly used diuretics and discuss their mechanism(s) of action with regards to their effects in the setting of heart failure. Then, we discuss the currently available data on the use of diuretics with special emphasis on the most recent trials in this field. Use of diuretics in cardiorenal syndromes (acute and chronic) has been a topic of interest that will be covered afterwards. Finally, we discuss challenging clinical situations such as diuretic resistance and monitoring of the volume status in patients with heart failure and provide the readers with relevant solutions. At the end, we briefly discuss the complementary use of ultrafiltration therapy along with diuretics in the setting of heart failure and cardiorenal syndrome.
[Show abstract][Hide abstract] ABSTRACT: Heart failure remains the leading cause of hospitalization in older patients and is considered a growing public health problem with a significant financial burden on the health care system. The suboptimal efficacy and safety profile of diuretic-based therapeutic regimens coupled with unsatisfactory results of the studies on novel pharmacologic agents have positioned ultrafiltration on the forefront as an appealing therapeutic option for patients with acute decompensated heart failure (ADHF). In recent years, substantial interest in the use of ultrafiltration has been generated due to the advent of dedicated portable devices and promising results of trials focusing both on mechanistic and clinical aspects of this therapeutic modality. This article briefly reviews the proposed benefits of ultrafiltration therapy in the setting of ADHF and summarizes the major findings of the currently available studies in this field. The results of more recent trials on cardiorenal syndrome that present a counterpoint to previous observations and highlight certain limitations of ultrafiltration therapy are then discussed, followed by identification of major challenges and unanswered questions that could potentially hinder its more widespread use. Future studies are warranted to shed light on less well characterized aspects of ultrafiltration therapy and to further define its role in ADHF and cardiorenal syndrome.
Preview · Article · May 2013 · Clinical Journal of the American Society of Nephrology
[Show abstract][Hide abstract] ABSTRACT: Synthetic cannabinoids (SCs) have emerged as drugs of abuse with increasing popularity among young adults. The potential renal
complication related to the abuse of SC was not recognized until recently. Here, we present a case of severe acute kidney
injury (AKI) that developed after inhalation of SC in an otherwise healthy young patient. A kidney biopsy revealed severe
acute tubular necrosis, and supportive management resulted in the recovery of the kidney function. Herein, we briefly summarize
the only two previous reports (a total of 21 cases) on the association between SC abuse and renal dysfunction and identify
the common aspects in all observations.
[Show abstract][Hide abstract] ABSTRACT: Background:
Heart failure (HF) has a high readmission rate in part due to conventional and recently developed therapeutic options having suboptimal results. Extracorporeal and peritoneal ultrafiltration have been advocated as more beneficial methods for fluid removal in decompensated or refractory HF, respectively.
Traditional and emerging concepts explaining the pathophysiology of HF and the cardiorenal syndrome are reviewed. Extracorporeal and peritoneal ultrafiltration clinical trials are then discussed in terms of potential physiologic benefits, feasibility and their effects on both cardiac and renal function.
Ultrafiltration therapy can efficiently correct volume overload in the acute setting, improve cardiac functional and quality of life parameters, and is associated with long-lasting benefits such as reduced HF-related readmissions. Although excessive fluid removal can adversely affect the kidneys, there is evidence that careful protocols can restore diuretic sensitivity and maintain stable renal function; crafting safe parameters has yet to be studied.
While extracorporeal ultrafiltration is an appealing therapeutic option for patients with acute decompensated HF, determining the optimal fluid removal rate and the impact on renal function need further investigation. Peritoneal dialysis may be an appropriate alternative in the setting of chronic refractory HF, but controlled studies are needed. Further trials are warranted to determine the long-term outcomes from both ultrafiltration modalities in HF.
No preview · Article · Oct 2012 · Blood Purification