心力衰竭伴肾功能不良的治疗策略

Treatment strategies for heart failure with renal dysfunction

心力衰竭合并肾功能恶化或慢性肾病对预后有严重影响。充血和灌注不足均可导致肾髓质血流紊乱,是心力衰竭肾损伤的主要原因。袢利尿剂是治疗充血性心力衰竭的一线药物,但可引起肾功能下降的不良反应和利尿剂抵抗。托伐普坦是一种新型的排自由水利尿剂,其作用机制与以往的排钠袢利尿剂完全不同;托伐普坦还能消除肾脏充血,改善髓质血流量,故对于心肾综合征是一个合适的选择。临床应用中托伐普坦不激活肾素-血管紧张素-醛固酮系统,不引起电解质紊乱,不降低血压,肾功能不全患者无禁忌,而且安全无严重不良反应。对于晚期肾病患者,托伐普坦仍然有效。对于充血性心力衰竭伴肾功能不全的患者,最好的治疗策略是加服托伐普坦以及减少袢利尿剂剂量。

Patients with heart failure combined with worsening renal function(WRF) or chronic kidney disease(CKD) have a serious impact on the prognosis.Both congestion and insufficient perfusion can lead to renal medullary blood flow disorder,which is the main cause of renal injury in heart failure.Loop diuretics are the first-line medications for congestive heart failure,however,they are associated with serious adverse effects,including decreased renal function and diuretic resistance.Tolvaptan is a new type of free water diuretic,which has a completely different mechanism from the previous sodium expulsion loop diuretics.Tolvaptan can also eliminate kidney congestion and improve medullary blood flow,and is a appropriate choice for cardiorenal syndrome.In the clinical application,tolvaptandoes not activate rein-angiotensin-aldosterone-system(RAAS),does not cause electrolyte disturbance,and does not reduce blood pressure.It have no contraindications and serious adverse reactionsin patients with renal insufficiency.Tolvaptan is still effective in patients with advanced nephropathy.For patients with congestive heart failure and renal dysfunction,the best treatment strategy is to add tolvaptan and reduce loop diuretics.