title: Intensification of Medication Therapy for Cardiorenal Syndrome in Acute Decompensated Heart Failure.
abstract: BACKGROUND
  Worsening renal function in heart failure may be related to increased venous congestion, decreased cardiac output, or both. Diuretics are universally used in acute decompensated heart failure, but they may be ineffective and may lead to azotemia. We aimed to compare the decongestive properties of a urine output-guided diuretic adjustment and standard therapy for the management of cardiorenal syndrome in acute decompensated heart failure.
  
  
  RESULTS
  Data were pooled from subjects randomized to the stepwise pharmacologic care algorithm (SPCA) in the CARRESS-HF trial and those who developed cardiorenal syndrome (rise in creatinine >0.3 mg/dL) in the DOSE-AHF and ROSE-AHF trials. Patients treated with SPCA (n = 94) were compared with patients treated with standard decongestive therapy (SDT) that included intravenous loop diuretic use (DOSE-AHF and ROSE-AHF; n = 107) at the time of cardiorenal syndrome and followed for net fluid balance, weight loss, and changing renal function. The SPCA group had higher degrees of jugular venous pressure (P < .0001) at the time of cardiorenal syndrome. The group that received SPCA had more weight change (-3.4 ± 5.2 lb) and more net fluid loss (1.705 ± 1.417 L) after 24 hours than the SDT group (-0.8 ± 3.4 lb and 0.892 ± 1.395 L, respectively; P < .001 for both) with a slight improvement in renal function (creatinine change -0.1 ± 0.3 vs 0.0 ± 0.3 mg/dL, respectively; P = .03).
  
  
  CONCLUSIONS
  Compared with SDT, patients who received an intensification of medication therapy for treating persisting congestion had greater net fluid and weight loss without being associated with renal compromise.
authors.affiliation: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Justin L
authors.initials: JL
authors.lastname: Grodin
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Susanna R
authors.initials: SR
authors.lastname: Stevens
authors.affiliation: Washington University School of Medicine, St Louis, Missouri.
authors.forename: Lisa
authors.initials: L
authors.lastname: de las Fuentes
authors.affiliation: Cardiovascular Center, Tufts Medical Center, Boston, Massachusetts.
authors.forename: Michael
authors.initials: M
authors.lastname: Kiernan
authors.affiliation: Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Edo Y
authors.initials: EY
authors.lastname: Birati
authors.affiliation: Cardiology Division, Emory University, Atlanta, Georgia.
authors.forename: Divya
authors.initials: D
authors.lastname: Gupta
authors.affiliation: Hennepin County Medical Center, Minneapolis, Minnesota.
authors.forename: Bradley A
authors.initials: BA
authors.lastname: Bart
authors.affiliation: Duke University Medical Center and Duke Heart Center, Durham, North Carolina.
authors.forename: G Michael
authors.initials: GM
authors.lastname: Felker
authors.affiliation: Mayo Clinic, Rochester, Minnesota.
authors.forename: Horng H
authors.initials: HH
authors.lastname: Chen
authors.affiliation: Cardiology Division, Emory University, Atlanta, Georgia.
authors.forename: Javed
authors.initials: J
authors.lastname: Butler
authors.affiliation: Washington University School of Medicine, St Louis, Missouri.
authors.forename: Victor G
authors.initials: VG
authors.lastname: Dávila-Román
authors.affiliation: Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Kenneth B
authors.initials: KB
authors.lastname: Margulies
authors.affiliation: Duke University Medical Center and Duke Heart Center, Durham, North Carolina.
authors.forename: Adrian F
authors.initials: AF
authors.lastname: Hernandez
authors.affiliation: Duke Clinical Research Institute, Durham, North Carolina.
authors.forename: Kevin J
authors.initials: KJ
authors.lastname: Anstrom
authors.affiliation: Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio. Electronic address: tangw@ccf.org.
authors.forename: W H Wilson
authors.initials: WH
authors.lastname: Tang
mesh_terms: D000208:Acute Disease; D000368:Aged; D053099:Azotemia / Q000517:prevention & control; D059347:Cardio-Renal Syndrome / Q000188:drug therapy*; D002316:Cardiotonic Agents / Q000008:administration & dosage / Q000627:therapeutic use*; D003404:Creatinine / Q000097:blood; D003422:Critical Care; D004231:Diuresis; D004232:Diuretics / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use*; D005260:Female; D006801:Humans; D007275:Injections, Intravenous; D008297:Male; D008875:Middle Aged; D016032:Randomized Controlled Trials as Topic; D014462:Ultrafiltration; D014665:Vasodilator Agents / Q000008:administration & dosage / Q000627:therapeutic use*
chemical_list: D002316:Cardiotonic Agents; D004232:Diuretics; D014665:Vasodilator Agents; D003404:Creatinine
keywords: Acute decompensated heart failure; cardiorenal syndrome; diuretics