CORRESPONDENCE: LETTER TO THE EDITOR
Relationship of Venous Congestion to Worsening Renal Function
Farhan Maqsood, MD and
Harold M. Szerlip, MD*
* Medical College of Georgia, Room BI 5072, 1120 15th Street, Augusta, Georgia 30912 (Email: hszerlip{at}mcg.edu).
We read with considerable interest the article by Mullens et al. (1) as well as the accompanying editorial by Jessup and Constanzo (2). Although we do not doubt that venous congestion plays a role in glomerular filtration, the article lacks important data. Those patients with worsening renal function appear to have the greatest change in central venous pressure (CVP). This raises the concern that they were more vigorously diuresed and possibly received higher doses of diuretic. This may have activated tubular glomerular feedback with a decrease in glomerular filtration rate. The authors need to provide more data on fluid balance and diuretic dose in order to support that the worsening of renal function was independently associated with CVP. In the accompanying editorial, the authors suggest that ultrafiltration if maintained at a rate of 14 to 15 ml/min will not activate the renin-angiotensin-aldosterone system. We know of no recent data to support that conclusion. The UNLOAD (Ultrafiltration Versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Heart Failure) study (3) has never published results of neurohormonal measurements, and no recent study has shown a renal benefit of ultrafiltration over intravenous diuretics. Rogers et al. (4) recently showed in a small substudy of patients in the UNLOAD study that there were no renal hemodynamic differences between diuretics and ultrafiltration.
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1. Mullens W, Abrahams Z, Francis GS, et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure J Am Coll Cardiol 2009;53:589-596.[Abstract/Free Full Text]2. Jessup M, Constanzo MR. The cardiorenal syndrome: do we need a change in strategy or a change in tactics? J Am Coll Cardiol 2009;53:597-599.[Free Full Text] 3. Constanzo 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.[Abstract/Free Full Text] 4. Rogers HL, Marshall J, Bock J. A randomized, controlled trial of the renal effects of ultrafiltration as compared to furosemide in patients with acute decompensated heart failure J Cardiac Fail 2008;14:1-5.[CrossRef][Web of Science][Medline]
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