症状恶化的一个常见原因是心肾综合征,为降低充血性心力衰竭症状,结果使肾功能逐渐下降。这些患者因使用利尿剂和血管紧张素转换酶抑制剂出现受损反应,且使用地高辛治疗时不良反应的风险增加。[221]Philbin EF, Santella RN, Rocco TA Jr. Angiotensin-converting enzyme inhibitor use in older patients with heart failure and renal dysfunction. J Am Geriatr Soc. 1999 Mar;47(3):302-8.
http://www.ncbi.nlm.nih.gov/pubmed/10078892?tool=bestpractice.com
[222]Arnold SB, Byrd RC, Meister W, et al. Long-term digitalis therapy improves left ventricular function in heart failure. N Engl J Med. 1980 Dec 18;303(25):1443-8.
http://www.ncbi.nlm.nih.gov/pubmed/6776403?tool=bestpractice.com
[223]Turini GA, Waeber B, Brunner HR. The renin-angiotensin system in refractory heart failure: clinical, hemodynamic and hormonal effects of captopril and enalapril. Eur Heart J. 1983 Jan;4 (Suppl A):189-97.
http://www.ncbi.nlm.nih.gov/pubmed/6301835?tool=bestpractice.com
持续性或进行性肾脏功能损害与不良预后相关。[224]Weinfeld MS, Chertow GM, Stevenson LW. Aggravated renal dysfunction during intensive therapy for advanced chronic heart failure. Am Heart J. 1999 Aug;138(2 Pt 1):285-90.
http://www.ncbi.nlm.nih.gov/pubmed/10426840?tool=bestpractice.com
[225]Alpert MA. Cardiovascular factors influencing survival in dialysis patients. Adv Perit Dial. 1996;12:110-9.
http://www.ncbi.nlm.nih.gov/pubmed/8865884?tool=bestpractice.com
伴有终末期肾病的心力衰竭患者,其症状可能随着贫血和透析瘘管植入导致心脏负荷增加而加重。[226]Besarab A, Bolton WK, Browne JK, et al. The effects of normal as compared with low hematocrit values in patients with cardiac disease who are receiving hemodialysis and epoetin. N Engl J Med. 1998 Aug 27;339(9):584-90.
https://www.nejm.org/doi/10.1056/NEJM199808273390903
http://www.ncbi.nlm.nih.gov/pubmed/9718377?tool=bestpractice.com
多数患者能没有困难的忍受轻到中度的肾功能受损。然而,如果血清肌酐升高至 265 μmol/L (>3 mg/dL) 以上,肾功能不全可能严重限制治疗效果并增加治疗的毒副作用。[221]Philbin EF, Santella RN, Rocco TA Jr. Angiotensin-converting enzyme inhibitor use in older patients with heart failure and renal dysfunction. J Am Geriatr Soc. 1999 Mar;47(3):302-8.
http://www.ncbi.nlm.nih.gov/pubmed/10078892?tool=bestpractice.com
[227]Risler T, Schwab A, Kramer B, et al. Comparative pharmacokinetics and pharmacodynamics of loop diuretics in renal failure. Cardiology. 1994;84 (Suppl 2):155-61.
http://www.ncbi.nlm.nih.gov/pubmed/7954539?tool=bestpractice.com
肾功能受损者可能无法使用血管紧张素转换酶抑制剂和血管紧张素 Ⅱ 受体拮抗剂治疗。对血清肌酐>442 μmol/L (>5 mg/dL) 的患者,可能需要血液滤过或透析来控制液体潴留,将尿毒症风险降至最低,使患者能够忍受心力衰竭常规治疗药物,并对治疗有反应。[228]Iorio L. Daily hemofiltration in severe heart failure. Int J Artif Organs. 1998 Dec;21(12):778-80.
http://www.ncbi.nlm.nih.gov/pubmed/9988353?tool=bestpractice.com
[229]Iorio L, Nacca RG, Simonelli R, et al. Daily hemofiltration in severe heart failure. Miner Electrolyte Metab. 1999 Jan-Apr;25(1-2):39-42.
http://www.ncbi.nlm.nih.gov/pubmed/10207257?tool=bestpractice.com
[230]Iorio L, Simonelli R, Nacca RG, et al. Daily hemofiltration in severe heart failure. Kidney Int Suppl. 1997 Jun;59:S62-5.
http://www.ncbi.nlm.nih.gov/pubmed/9185107?tool=bestpractice.com
[231]Iorio L, Simonelli R, Nacca RG, et al. The benefits of daily hemofiltration in the management of anuria in patients with severe heart failure (NYHA IV). Int J Artif Organs. 1998 Aug;21(8):457-9.
http://www.ncbi.nlm.nih.gov/pubmed/9803347?tool=bestpractice.com
慢性肾功能衰竭 |