Please wait a minute...
Reviews in Cardiovascular Medicine  2019, Vol. 20 Issue (4): 263-266     DOI: 10.31083/j.rcm.2019.04.564
Case Report Previous articles | Next articles
Alterations in Doppler-derived renal venous stasis index during decompensation of right heart failure and fluid overload in a patient with pulmonary hypertension
Faeq Husain-Syed1, 2, 3, *(), Horst-Walter Birk1, Khodr Tello3, 4, Manuel J. Richter3, 4, Claudio Ronco2, Peter A. McCullough5, Tanja Schörmann1, Fiorenza Ferrari6, Gökhan Yücel7, Babak Yazdani8, Hans-Dieter Walmrath3, 4, Werner Seeger1, 3, 4, 9, Henning Gall3, 4, H. Ardeschir Ghofrani3, 4, 10
1 Department of Internal Medicine II, Division of Nephrology, University Hospital Giessen and Marburg, Klinikstrasse 33, 35392 Giessen, Germany
2 Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Via Rodolfi, 37-36100 Vicenza, Italy
3 Department of Internal Medicine II, Division of Pulmonology and Critical Care Medicine, University Hospital Giessen and Marburg, 35392, Giessen, Germany
4 Universities of Giessen and Marburg Lung Center (UGMLC) [member of the German Center for Lung Research (DZL)], Klinikstrasse 33, 35392, Giessen, Germany
5 Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, 621 N Hall Street, Dallas, Texas 75226, USA
6 Intensive Care Unit, I.R.C.C.S. Policlinico San Matteo, Viale Camillo Golgi, 19-27100 Pavia, Italy
7 First Department of Medicine, Faculty of Medicine, University Medical Center Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
8 Fifth Department of Medicine, Faculty of Medicine, University Medical Center Mannheim (UMM), University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
9 Max Planck Institute for Heart and Lung Research, Parkstrasse 1, 61231 Bad Nauheim, Germany
10 Department of Pulmonology, Kerckhoff-Klinik, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
Download:  PDF(402KB)  ( 1148 ) Full text   ( 56 )
Export:  BibTeX | EndNote (RIS)      
Abstract:

Renal congestion is becoming recognized as a potential contributor to cardiorenal syndromes. Adequate control of congestion with simultaneous preservation of renal function has been proposed as a central goal of the management of heart failure. We report our care of a 48-year-old woman suffering from right heart failure and massive fluid overload due to severe pulmonary hypertension secondary to a combination of left-heart disease and status after recurrent pulmonary embolisms. Alterations in Doppler-derived intrarenal venous flow patterns and a novel renal venous stasis index were used to evaluate improvement in renal venous congestion during decompensation. Due to refractory congestion despite optimal medical treatment and continuous veno-venous hemodialysis, a peritoneal dialysis catheter was placed to relieve the massive ascites. The paracentesis of ascites led to a significant loss of weight, normalization of hydration status with subsequent termination of continuous veno-venous hemodialysis, and a significant improvement in clinical and echocardiographic parameters. Renal Doppler ultrasonography showed continuous improvement in intrarenal venous flow patterns and the renal venous stasis index indicative of effective decongestion up to a normal intrarenal venous flow pattern and renal venous stasis index. Furthermore, residual renal function increased during follow-up. This case demonstrates the feasibility of renal Doppler ultrasonography as a simple, non-invasive, and integrative measure of renal congestion. The renal venous stasis index and intrarenal venous flow patterns may be useful to evaluate the treatment response and to guide therapy in patients with right heart failure.

Key words:  Cardiorenal syndromes      pulmonary hypertension      renal Doppler ultrasonography      venous congestion     
Submitted:  15 September 2019      Accepted:  28 November 2019      Published:  30 December 2019     
*Corresponding Author(s):  Faeq Husain-Syed     E-mail:  Faeq.Husain-Syed@innere.med.uni-giessen.de

Cite this article: 

Faeq Husain-Syed, Horst-Walter Birk, Khodr Tello, Manuel J. Richter, Claudio Ronco, Peter A. McCullough, Tanja Schörmann, Fiorenza Ferrari, Gökhan Yücel, Babak Yazdani, Hans-Dieter Walmrath, Werner Seeger, Henning Gall, H. Ardeschir Ghofrani. Alterations in Doppler-derived renal venous stasis index during decompensation of right heart failure and fluid overload in a patient with pulmonary hypertension. Reviews in Cardiovascular Medicine, 2019, 20(4): 263-266.

URL: 

https://rcm.imrpress.com/EN/10.31083/j.rcm.2019.04.564     OR     https://rcm.imrpress.com/EN/Y2019/V20/I4/263

Figure 1.  Time-course of body weight, invasive hemodynamics, right ventricular systolic function (TAPSE), neurohormonal activation (BNP), and residual renal function (eGFR using Chronic Kidney Disease Epidemiology Collaboration (Levey et al., 2009)) during hospital stay. A marked reduction in weight and BNP level, and an increase in TAPSE over time was seen after continuous relief from ascites, followed by progressive improvement in residual renal function. Dark-blue and pink bars denote CRRT and paracentesis of ascites/peritoneal ultrafiltration sessions, respectively. BNP, b-type natriuretic peptide; CRRT, continuous renal replacement therapy; eGFR, estimated glomerular filtration rate; ICU, intensive care unit; i.v., intravenous; mPAP, mean pulmonary artery pressure; PCWP, pulmonary capillary wedge pressure; PVR, pulmonary vascular resistance; RAP, right atrial pressure; IRVF, intrarenal venous flow; RVSI, renal venous stasis index; TAPSE, tricuspid annular plane systolic excursion.

Table 1.  At a glance commentary
• The renal venous stasis index (RVSI) is a new and integrative Doppler measure of renal venous congestion.
• RVSI indicates the proportion of the cardiac cycle during which there is no renal venous outlet flow and is calculated as (cardiac cycle time-venous flow time)/cardiac cycle time.
• The present case vignette presents the potential usefulness of RVSI as a dynamic marker of alterations in renal venous congestion secondary to right heart failure.
• RVSI may provide additional prognostic information in daily clinical practice to better characterize patients with cardiorenal syndromes.
• Longitudinal studies are needed to assess the utility of renal Doppler ultrasonography-estimated renal congestion to guide decongestive or heart failure therapy.
[1] Bart, B. A., Goldsmith, S. R., Lee, K. L., Givertz, M. M., O'Connor, C. M., Bull, D. A., Redfield, M. M., Deswal, A., Rouleau, J. L., LeWinter, M. M., Ofili, E. O., Stevenson, L. W., Semigran, M. J., Felker, G. M., Chen, H. H., Hernandez, A. F., Anstrom, K. J., McNulty, S. E., Velazquez, E. J., Ibarra, J. C., Mascette, A. M., Braunwald, E. and the Heart Failure Clinical Research Network. (2012) Ultrafiltration in decompensated heart failure with cardiorenal syndrome. The New England Journal of Medicine 367, 2296-2304.
doi: 10.1056/NEJMoa1210357 pmid: 23131078
[2] Damman, K., van Deursen, V. M., Navis, G., Voors, A. A., van Veldhuisen, D. J. and Hillege, H. L. (2009) Increased central venous pressure is associated with impaired renal function and mortality in a broad spectrum of patients with cardiovascular disease. Journal of the American College of Cardiology 53, 582-588.
doi: 10.1016/j.jacc.2008.11.012 pmid: 19215832
[3] Iida, N., Seo, Y., Sai, S., Machino-Ohtsuka, T., Yamamoto, M., Ishizu, T., Kawakami, Y. and Aonuma, K. (2016) Clinical Implications of Intrarenal Hemodynamic Evaluation by Doppler Ultrasonography in Heart Failure. Journal of the American College of Cardiology Heart Fail 4, 674-682.
doi: 10.1016/j.jchf.2016.03.016 pmid: 27179835
[4] Jessup, M. and Costanzo, M. R. (2009) The cardiorenal syndrome: do we need a change of strategy or a change of tactics? Journal of the American College of Cardiology 53, 597-599.
doi: 10.1016/j.jacc.2008.11.012 pmid: 19215834
[5] Galie, N., Humbert, M., Vachiery, J. L., Gibbs, S., Lang, I., Torbicki, A., Simonneau, G., Peacock, A., Vonk Noordegraaf, A., Beghetti, M., Ghofrani, A., Gomez Sanchez, M. A., Hansmann, G., Klepetko, W., Lancellotti, P., Matucci, M., McDonagh, T., Pierard, L. A., Trindade, P. T., Zompatori, M., Hoeper, M. and the ESC Scientific Document Group. (2016) 2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT). European Heart Journal 37, 67-119.
doi: 10.1093/eurheartj/ehv317 pmid: 26320113
[6] Guazzi, M., Vicenzi, M., Arena, R. and Guazzi, M. D. (2011) Pulmonary hypertension in heart failure with preserved ejection fraction: a target of phosphodiesterase-5 inhibition in a 1-year study. Circulation 124, 164-174.
doi: 10.1161/CIRCULATIONAHA.110.983866
[7] Husain-Syed, F., Birk, H-W Ronco, C., Schörmann, T., Tello, K., Richter, M. J., Sommer, N., Wilhelm, J., Steyerberg, E., Bauer, P., Walmrath, H-D Seeger, W., McCullough, P. A., Gall, H. and Ghofrani, H. A. (2019) Doppler-derived renal venous stasis index in the prognosis of right heart failure. Journal of the American Heart Association 8, e013584.
doi: 10.1161/JAHA.119.013584 pmid: 31630601
[8] Lammers, A. E., Haworth, S. G. and Pierce, C. M. (2006) Intravenous sildenafil as an effective treatment of pulmonary hypertensive crises during acute intestinal malabsorption. Cardiology in the Young 16, 84-86.
doi: 10.1017/S1047951105002155 pmid: 16454884
[9] Levey, A. S., Stevens, L. A., Schmid, C. H., Zhang, Y. L., Castro, A. F., 3rd, Feldman, H. I., Kusek, J. W., Eggers, P., Van Lente, F., Greene, T., Coresh, J. and the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration). (2009) A new equation to estimate glomerular filtration rate. Annals of Internal Medicine 150, 604-612.
doi: 10.7326/0003-4819-150-9-200905050-00006 pmid: 19414839
[10] Mullens, W., Abrahams, Z., Francis, G.S., Sokos, G., Taylor, D. O., Starling, R. C., Young, J. B. and Tang, W. H. (2009) Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. Journal of the American College of Cardiology 53, 589-596.
doi: 10.1016/j.jacc.2008.05.068 pmid: 19215833
[11] Mullens, W., Abrahams, Z., Skouri, H. N., Francis, G. S., Taylor, D. O., Starling, R. C., Paganini, E. and Tang, W. H. (2008) Elevated intra-abdominal pressure in acute decompensated heart failure: a potential contributor to worsening renal function? Journal of the American College of Cardiology 51, 300-306.
doi: 10.1016/j.jacc.2007.09.043
[12] Nijst, P., Martens, P., Dupont, M., Tang, W. H. W. and Mullens, W. (2017) Intrarenal Flow Alterations During Transition From Euvolemia to Intravascular Volume Expansion in Heart Failure Patients. Journal of the American College of Cardiology Heart Fail 5, 672-681.
doi: 10.1016/j.jchf.2017.05.006 pmid: 28711449
[13] Olsson, K. M., Halank, M., Egenlauf, B., Fistera, D., Gall, H., Kaehler, C., Kortmann, K., Kramm, T., Lichtblau, M., Marra, A. M., Nagel, C., Sablotzki, A., Seyfarth, H. J., Schranz, D., Ulrich, S., Hoeper, M. M. and Lange, T. J. (2018) Decompensated right heart failure, intensive care and perioperative management in patients with pulmonary hypertension: Updated recommendations from the Cologne Consensus Conference 2018. International Journal of Cardiology 272S, 46-52.
doi: 10.1016/j.ijcard.2018.08.081 pmid: 30190155
[14] Price, L. C., Wort, S. J., Finney, S. J., Marino, P. S. and Brett, S. J. (2010) Pulmonary vascular and right ventricular dysfunction in adult critical care: current and emerging options for management: a systematic literature review. Critical Care 14, R169.
doi: 10.1186/cc9264 pmid: 20858239
[15] Puzzovivo, A., Monitillo, F., Guida, P., Leone, M., Rizzo, C., Grande, D., Ciccone, M. M. and Iacoviello, M. (2018) Renal Venous Pattern: A New Parameter for Predicting Prognosis in Heart Failure Outpatients. Journal of Cardiovascular Development and Disease 5, pii: E52.
doi: 10.3390/jcdd5040052 pmid: 30400289
[16] Ronco, C., Haapio, M., House, A. A., Anavekar, N. and Bellomo, R. (2008) Cardiorenal syndrome. Journal of the American College of Cardiology 52, 1527-1539.
doi: 10.1016/j.jacc.2008.07.051
[1] Malik Bisserier, Natasha Pradhan, Lahouaria Hadri. Current and emerging therapeutic approaches to pulmonary hypertension[J]. Reviews in Cardiovascular Medicine, 2020, 21(2): 163-179.
[2] Davide Bolignano, Anna Pisano, Graziella D’Arrigo. Pulmonary hypertension: a neglected risk condition in renal patients?[J]. Reviews in Cardiovascular Medicine, 2018, 19(4): 117-121.
[3] Tariq Bhat, Adi Neuman, Mohmad Tantary, Hilal Bhat, Daniel Glass, William Mannino, Muhammad Akhtar, Alina Bhat, Sumaya Teli, James Lafferty. Inhaled Nitric Oxide in Acute Pulmonary Embolism: A Systematic Review[J]. Reviews in Cardiovascular Medicine, 2015, 16(1): 1-8.
[4] Michael S. Lee, Ehtisham Mahmud. Percutaneous Revascularization for Left Main Coronary Artery Compression From Pulmonary Artery Enlargement Due to Pulmonary Hypertension[J]. Reviews in Cardiovascular Medicine, 2012, 13(1): 32-36.
[5] Vishal Kapur, Christopher V. Chien, Justin E. Fuess, Ernst R. Schwarz. The Relationship Between Erectile Dysfunction and Cardiovascular Disease. Part II: The Role of PDE-5 Inhibition in Sexual Dysfunction and Cardiovascular Disease[J]. Reviews in Cardiovascular Medicine, 2008, 9(3): 187-195.
[6] Stacey B. Gross, Norman E. Lepor. Anorexigen-Related Cardiopulmonary Toxicity[J]. Reviews in Cardiovascular Medicine, 2000, 1(2): 80-89.
No Suggested Reading articles found!