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

• Published in: Journal of the American College of Cardiology Vol. 53; no. 7; pp. 589 - 596
• Main Authors: Mullens, Wilfried, MD, Abrahams, Zuheir, MD, PhD, Francis, Gary S., MD, FACC, Sokos, George, DO, Taylor, David O., MD, FACC, Starling, Randall C., MD, MPH, FACC, Young, James B., MD, FACC, Tang, W.H. Wilson, MD, FACC
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 17-02-2009; Elsevier; Elsevier Limited
• Subjects: Aged; Biological and medical sciences; Blood pressure; Capillary pressure; cardiac index; Cardiac Output; Cardiology; Cardiology. Vascular system; Cardiovascular; Catheters; Central Venous Pressure; Congestion; Creatinine; Creatinine - blood; decompensated heart failure; Drug therapy; Enzymes; Family medical history; Female; Heart; Heart diseases; Heart failure; Heart Failure - blood; Heart Failure - physiopathology; Heart failure, cardiogenic pulmonary edema, cardiac enlargement; Hemodynamics; Humans; Hyperemia - blood; Hyperemia - complications; Hyperemia - physiopathology; Intensive care; Internal Medicine; Kidney Diseases - blood; Kidney Diseases - etiology; Kidney Diseases - physiopathology; Male; Medical instruments; Medical sciences; Middle Aged; Patients; Pulmonary arteries; Pulmonary artery; Renal function; Severity of Illness Index; Studies; Therapy; Variables; Veins & arteries; venous congestion; Ventricle; worsening renal function; Cleveland Ohio; United States > US; glomerular filtration rate; CI; decompensated heart failure; cardiac index; pulmonary artery catheter; PCWP; advanced decompensated heart failure; pulmonary capillary wedge pressure; WRF; central venous pressure; GFR; venous congestion; PAC; worsening renal function; CVP; ADHF; Heart failure; Renal function; Heart disease; Cardiovascular disease; Advanced stage; Circulatory system; Cardiology; Vein; Aggravation
• ISSN: 0735-1097; 1558-3597
• DOI: 10.1016/j.jacc.2008.05.068

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.