CHF with multiple organ failure -> 救心臟似乎比較重要，對6月後survival來說，但目前未定論!!
在ICU裏面，CHF WITH PRE-RENAL AZOTEMIA, PULMOANRY CONGESTION
心臟科要脫水，腎臟科要給水，怎麼辦?
台灣的話，胸腔科可以插手，用VENTILATOR躲過去…呵
這篇文章說脫水比較活得久，可是沒有說後來洗腎的有多少??
這篇文章的病人是 EF 19-20%, CRE平均1.5-1.6，總共住院才7-9天……
還不是太爛的病人，純心臟不好而已，和臨床看到的有差…
其實是有道理，脫水讓他不要死，腎可以慢慢洗…當然活得久
By Genevra Pittman
NEW YORK (Reuters Health) Jul 22 - Aggressive diuresis may lead to better survival for patients with decompensated heart failure - even when it contributes to worsening renal function, suggests a new study.
Renal function clearly takes a hit when intravascular volume declines. But when the researchers analyzed patients with acute decompensated heart failure who were treated with aggressive fluid removal, they found - unexpectedly - that volume depletion (as indicated by hemoconcentration) was linked with better six-month survival.
That finding "says something that is surprising to everybody," Dr. Amir Kazory, a nephrology and heart failure researcher at the University of Florida who was not involved in the study, told Reuters Health. "So far, we have always thought that worsening renal function is a well-known predictor of mortality in patients who are admitted with decompensated heart failure. This article is questioning that."
At the University of Pennsylvania School of Medicine in Philadelphia, Dr. Jeffrey Testani and colleagues looked at data on 336 participants in a study of pulmonary artery catheter use in congestive heart failure.
The authors compared patients' loop diuretics dosage with their cardiac and renal function and with baseline-to-discharge changes in hemoconcentration markers (i.e., hematocrit, albumin, and total protein). Patients in the top tertile for at least two of the three markers were considered to have evidence of hemoconcentration.
Patients with hemoconcentration had been on higher doses of loop diuretics than those with smaller changes in intravascular fluid concentration (360 vs. 240 mg, p = 0.029). They also had a higher rate of diuresis (0.83 vs. 0.56 L/day, p = 0.035) and total volume of fluid lost (6.1 vs. 3.8 L, p = 0.039). Finally, their weight loss was faster (0.95 vs. 0.45 kg/d, p<0.001) and greater (6.3 vs. 2.7 kg, p<0.001).
The hemoconcentration group also had 43.5 times the odds of non-hemoconcentration patients of having a significantly worsening versus an improving glomerular filtration rate (p < 0.001).
This was expected.
What was not expected was that worsening renal function was not tied to mortality (HR = 1.6, p = 0.11), and hemoconcentration was associated with a significantly lower risk of mortality at 180 days (HR = 0.31, p = 0.016).
The lower mortality risk persisted after adjustment for multiple clinical factors (HR 0.16, p = 0.001).
"Most doctors and investigators have considered pushing the kidney function to get worse is a bad problem," Dr. W. H. Wilson Tang, a cardiologist at the Cleveland Clinic, told Reuters Health by e-mail. "It still is, but what this paper shows is that there are good outcomes when effective decongestion is achieved."
However, he continued, the difference in survival rate could mean that patients with persistent congestion didn't respond to diuretics and died sooner than those who did respond.
Dr. Testani said that while worsening renal function is generally associated with quicker death for patients with heart failure, "it probably depends on how you get there." If a patient has a predisposition to kidney problems, that likely puts them at a higher risk for mortality, he said.
But, "my theory (is that) if it's the treatment that causes the worsening renal function, it may not be bad for you," he said. "Certainly this study hints at that."
"If the physician is to choose between complete decongestion plus worsening renal function versus incomplete decongestion and preserving renal function, based on this study we should go for the first choice," said Dr. Kazory.
While this study challenges current assumptions by suggesting that aggressive decongestion may do more long-term good than harm, the findings are preliminary and require replication, especially in a randomized trial, the authors write.
Dr. Kazory agreed. "Would (this finding) change our practice in the future or not? We just don't know yet," he said. "Certainly at this point it does not and it should not change our practice."
SOURCE: http://link.reuters.com/nam58m
Circ 2010;122:265-272.
https://docs.google.com/fileview?id=0B278nGJMQBk7ZDJkMDliMzYtY2VlMy00MTdmLWE5MTEtZGU1MTkxM2UwZmMz&hl=zh_TW
心臟科要脫水，腎臟科要給水，怎麼辦?
台灣的話，胸腔科可以插手，用VENTILATOR躲過去…呵
這篇文章說脫水比較活得久，可是沒有說後來洗腎的有多少??
這篇文章的病人是 EF 19-20%, CRE平均1.5-1.6，總共住院才7-9天……
還不是太爛的病人，純心臟不好而已，和臨床看到的有差…
其實是有道理，脫水讓他不要死，腎可以慢慢洗…當然活得久
By Genevra Pittman
NEW YORK (Reuters Health) Jul 22 - Aggressive diuresis may lead to better survival for patients with decompensated heart failure - even when it contributes to worsening renal function, suggests a new study.
Renal function clearly takes a hit when intravascular volume declines. But when the researchers analyzed patients with acute decompensated heart failure who were treated with aggressive fluid removal, they found - unexpectedly - that volume depletion (as indicated by hemoconcentration) was linked with better six-month survival.
That finding "says something that is surprising to everybody," Dr. Amir Kazory, a nephrology and heart failure researcher at the University of Florida who was not involved in the study, told Reuters Health. "So far, we have always thought that worsening renal function is a well-known predictor of mortality in patients who are admitted with decompensated heart failure. This article is questioning that."
At the University of Pennsylvania School of Medicine in Philadelphia, Dr. Jeffrey Testani and colleagues looked at data on 336 participants in a study of pulmonary artery catheter use in congestive heart failure.
The authors compared patients' loop diuretics dosage with their cardiac and renal function and with baseline-to-discharge changes in hemoconcentration markers (i.e., hematocrit, albumin, and total protein). Patients in the top tertile for at least two of the three markers were considered to have evidence of hemoconcentration.
Patients with hemoconcentration had been on higher doses of loop diuretics than those with smaller changes in intravascular fluid concentration (360 vs. 240 mg, p = 0.029). They also had a higher rate of diuresis (0.83 vs. 0.56 L/day, p = 0.035) and total volume of fluid lost (6.1 vs. 3.8 L, p = 0.039). Finally, their weight loss was faster (0.95 vs. 0.45 kg/d, p<0.001) and greater (6.3 vs. 2.7 kg, p<0.001).
The hemoconcentration group also had 43.5 times the odds of non-hemoconcentration patients of having a significantly worsening versus an improving glomerular filtration rate (p < 0.001).
This was expected.
What was not expected was that worsening renal function was not tied to mortality (HR = 1.6, p = 0.11), and hemoconcentration was associated with a significantly lower risk of mortality at 180 days (HR = 0.31, p = 0.016).
The lower mortality risk persisted after adjustment for multiple clinical factors (HR 0.16, p = 0.001).
"Most doctors and investigators have considered pushing the kidney function to get worse is a bad problem," Dr. W. H. Wilson Tang, a cardiologist at the Cleveland Clinic, told Reuters Health by e-mail. "It still is, but what this paper shows is that there are good outcomes when effective decongestion is achieved."
However, he continued, the difference in survival rate could mean that patients with persistent congestion didn't respond to diuretics and died sooner than those who did respond.
Dr. Testani said that while worsening renal function is generally associated with quicker death for patients with heart failure, "it probably depends on how you get there." If a patient has a predisposition to kidney problems, that likely puts them at a higher risk for mortality, he said.
But, "my theory (is that) if it's the treatment that causes the worsening renal function, it may not be bad for you," he said. "Certainly this study hints at that."
"If the physician is to choose between complete decongestion plus worsening renal function versus incomplete decongestion and preserving renal function, based on this study we should go for the first choice," said Dr. Kazory.
While this study challenges current assumptions by suggesting that aggressive decongestion may do more long-term good than harm, the findings are preliminary and require replication, especially in a randomized trial, the authors write.
Dr. Kazory agreed. "Would (this finding) change our practice in the future or not? We just don't know yet," he said. "Certainly at this point it does not and it should not change our practice."
SOURCE: http://link.reuters.com/nam58m
Circ 2010;122:265-272.
https://docs.google.com/fileview?id=0B278nGJMQBk7ZDJkMDliMzYtY2VlMy00MTdmLWE5MTEtZGU1MTkxM2UwZmMz&hl=zh_TW
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