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J Am Coll Cardiol, 2009; 53:589-596, doi:10.1016/j.jacc.2008.05.068
© 2009 by the American College of Cardiology Foundation
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CLINICAL RESEARCH: HEART FAILURE

Importance of Venous Congestion for Worsening of Renal Function in Advanced Decompensated Heart Failure

Wilfried Mullens, MD, Zuheir Abrahams, MD, PhD, Gary S. Francis, MD, FACC, George Sokos, DO, David O. Taylor, MD, FACC, Randall C. Starling, MD, MPH, FACC, James B. Young, MD, FACC and W.H. Wilson Tang, MD, FACC*

Department of Cardiovascular Medicine, Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio

Manuscript received February 8, 2008; revised manuscript received May 14, 2008, accepted May 19, 2008.

* Reprint requests and correspondence to: Dr. W. H. Wilson Tang, Heart and Vascular Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, Ohio 44195 (Email: tangw{at}ccf.org).

Objectives: To determine whether venous congestion, rather than impairment of cardiac output, is primarily associated with the development of worsening renal function (WRF) in patients with advanced decompensated heart failure (ADHF).

Background: Reduced cardiac output is traditionally believed to be the main determinant of WRF in patients with ADHF.

Methods: A total of 145 consecutive patients admitted with ADHF treated with intensive medical therapy guided by pulmonary artery catheter were studied. We defined WRF as an increase of serum creatinine ≥0.3 mg/dl during hospitalization.

Results: In the study cohort (age 57 ± 14 years, cardiac index 1.9 ± 0.6 l/min/m2, left ventricular ejection fraction 20 ± 8%, serum creatinine 1.7 ± 0.9 mg/dl), 58 patients (40%) developed WRF. Patients who developed WRF had a greater central venous pressure (CVP) on admission (18 ± 7 mm Hg vs. 12 ± 6 mm Hg, p < 0.001) and after intensive medical therapy (11 ± 8 mm Hg vs. 8 ± 5 mm Hg, p = 0.04). The development of WRF occurred less frequently in patients who achieved a CVP <8 mm Hg (p = 0.01). Furthermore, the ability of CVP to stratify risk for development of WRF was apparent across the spectrum of systemic blood pressure, pulmonary capillary wedge pressure, cardiac index, and estimated glomerular filtration rates.

Conclusions: Venous congestion is the most important hemodynamic factor driving WRF in decompensated patients with advanced heart failure.

Key Words: worsening renal function • venous congestion • cardiac index • decompensated heart failure

Abbreviations and Acronyms
  ADHF = advanced decompensated heart failure
  CI = cardiac index
  CVP = central venous pressure
  GFR = glomerular filtration rate
  PAC = pulmonary artery catheter
  PCWP = pulmonary capillary wedge pressure
  WRF = worsening renal function


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