Background The relationship between intensive volume removal in acute decompensated heart failure patients with preexisting worsening renal function (WRF) and renal tubular injury, postdischarge renal function, and clinical outcomes is unknown. Methods and Results We used data from the multicenter CARRESS-HF trial (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) that randomized patients with acute decompensated heart failure and preexisting WRF to intensive volume removal with stepped pharmacological therapy or fixed rate ultrafiltration. Patients in the urinary renal tubular injury biomarker substudy (NAG [N-acetyl-b-D-glucosaminidase], KIM-1 [kidney injury molecule-1], and NGAL [neutrophil gelatinase-associated lipocalin]) were evaluated (N=105). The severity of prerandomization WRF was unrelated to baseline renal tubular injury biomarkers ( r=0.14; P=0.17). During randomized intensive volume removal, creatinine further worsened in 53% of patients. Despite a small to moderate magnitude increase in creatinine in most of these patients, postrandomization WRF was strongly associated with worsening in renal tubular injury biomarkers (odds ratio, 12.6; P=0.004). This observation did not differ by mode of volume removal (stepped pharmacological therapy versus ultrafiltration, Pinteraction=0.46). Increase in renal tubular injury biomarkers was associated with a higher incidence of hemoconcentration (odds ratio, 3.1; P=0.015), and paradoxically, better recovery of creatinine at 60 days ( P=0.01). Conclusions In acute decompensated heart failure patients with preexisting WRF, intensive volume removal resulted in a further worsening of creatinine approximately half of the time, a finding associated with a rise in tubular injury biomarkers. However, decongestion and renal function recovery at 60 days were superior in patients with increased tubular injury markers. These data suggest that the benefits of decongestion may outweigh any modest or transient increases in serum creatinine or tubular injury markers that occur during intensive volume removal. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00608491.

中文翻译：

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曾有肾脏功能恶化的心力衰竭患者强化容量清除术对肾脏的影响。

背景急性失代偿性心力衰竭患者先前已存在肾功能恶化（WRF）和肾小管损伤，出院后肾功能与临床结局之间的大量清除之间的关系尚不清楚。方法和结果我们使用了多中心CARRESS-HF试验（急性失代偿性心力衰竭的心肾救治研究）中的数据，该数据将急性失代偿性心力衰竭和已有WRF的患者随机分配至采用逐步药物治疗或固定速率超滤进行大剂量清除。评估了泌尿肾小管损伤生物标志物亚组（NAG [N-乙酰基-bD-氨基葡萄糖苷酶]，KIM-1 [肾损伤分子-1]和NGAL [中性粒细胞明胶酶相关脂质运载蛋白]）的患者（N = 105）。随机前WRF的严重程度与基线肾小管损伤生物标志物无关（r = 0.14； P = 0.17）。在随机进行的大量排毒期间，肌酐进一步恶化的患者占53％。尽管大多数这些患者的肌酐水平有小到中等的增加，但随机化后的WRF与肾小管损伤生物标志物的恶化密切相关（比值比为12.6； P = 0.004）。该观察结果在体积去除模式上没有差异（阶梯式药理疗法与超滤比较，Pinteraction = 0.46）。肾小管损伤生物标志物的增加与血药浓度更高的发生率（比值比为3.1； P = 0.015）有关，反之，肌酐在60天时的恢复较好（P = 0.01）。结论在急性失代偿性心力衰竭患者中已有WRF，大量去除体积导致肌酐进一步恶化，大约一半时间，这一发现与肾小管损伤生物标志物的升高有关。然而，肾小管损伤指标增加的患者在60天时充血和肾功能恢复良好。这些数据表明，充血的好处可能会超过在大量清除过程中发生的血清肌酐或肾小管损伤标志物适度或短暂的增加。临床试验注册网址：https://www.clinicaltrials.gov。唯一标识符：NCT00608491。这些数据表明，充血的好处可能会超过在大量清除体内发生的血清肌酐或肾小管损伤标志物适度或短暂的增加。临床试验注册网址：https://www.clinicaltrials.gov。唯一标识符：NCT00608491。这些数据表明，充血的好处可能会超过在大量清除过程中发生的血清肌酐或肾小管损伤标志物适度或短暂的增加。临床试验注册网址：https://www.clinicaltrials.gov。唯一标识符：NCT00608491。