medicina59巻12号

2022年11月発行

特集 避けて通れない心不全診療—総合内科力・循環器力を鍛えよう！ 急性心不全

利尿薬：急性心不全にて利尿薬使用中に血清Cr値が上がったら，うっ血があっても利尿薬を中止したほうがよいですか？

著者： 高野敬佑¹ 北村浩一¹ 鈴木利彦¹

所属機関： ¹東京ベイ・浦安市川医療センター腎臓・内分泌・糖尿病内科

ページ範囲：P.2152 - P.2156

Point
◎心不全治療中の血清Cr値はリアルタイムの腎機能を反映したものではない．
◎急性心不全ではさまざまな理由で血清Cr値が上昇し，原因は利尿薬だけではない．
◎利尿薬治療中の血清Cr値上昇は，必ずしも生命予後悪化や腎予後悪化と関連しない．
◎うっ血が残存しているにもかかわらず血清Cr値の上昇のために利尿薬治療を中止すると，かえって生命予後が悪化してしまう可能性がある．

参考文献

1）Nohria A, et al：Clinical assessment identifies hemodynamic profiles that predict outcomes in patients admitted with heart failure. J Am Coll Cardiol 41：1797-1804, 2003

2）Harjola VP, et al：Organ dysfunction, injury and failure in acute heart failure；From pathophysiology to diagnosis and management. A review on behalf of the Acute Heart Failure Committee of the Heart Failure Association（HFA）of the European Society of Cardiology（ESC）. Eur J Heart Fail 19：821-836, 2017

3）Rubio-Gracia J, et al：Prevalence, predictors and clinical outcome of residual congestion in acute decompensated heart failure. Int J Cardiol 258：185-191, 2018

4）Damman K, et al：Renal impairment, worsening renal function, and outcome in patients with heart failure；An updated meta-analysis. Eur Heart J 35：455-469, 2014

5）Yamada T, et al：Systematic review of the association between worsening renal function and mortality in patients with acute decompensated heart failure. Kidney Int Rep 5：1486-1494, 2020

6）Moran SM, et al：Course of acute renal failure studied by a model of creatinine kinetics. Kidney Int 27：928-937, 1985

7）Swolinsky JS, et al：Serum creatinine and cystatin C-based estimates of glomerular filtration rate are misleading in acute heart failure. ESC Heart Fail 8：3070-3081, 2021

8）Damman K, et al：The kidney in heart failure；An update. Eur Heart J 36：1437-1444, 2015

9）Weinfeld MS, et al：Aggravated renal dysfunction during intensive therapy for advanced chronic heart failure. Am Heart J 138：285-290, 1999

10）Mullens W, et al：Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol 53（7）：589-596, 2009

10）Ahmad T, et al：Worsening renal function in patients with acute heart failure undergoing aggressive diuresis is not associated with tubular injury. Circulation 137：2016-2028, 2018

11）Damman K, et al：Decreased cardiac output, venous congestion and the association with renal impairment in patients with cardiac dysfunction. Eur J Heart Fail 9：872-878, 2007

12）Konstam MA, et al；Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan（EVEREST）investigators：Effects of oral tolvaptan in patients hospitalized for worsening heart failure；The EVEREST outcome trial. JAMA 297：1319-1331, 2007

13）McCallum W, et al：Rates of reversal of volume overload in hospitalized acute heart failure；Association with long-term kidney function. Am J Kidney Dis 80：65-78, 2021

14）Oguri M, et al：Efficacy of rapid decongestion strategy in patients hospitalized for acute heart failure. Circ J 84：958-964, 2020.

15）Rao VS, et al：Renal effects of intensive volume removal in heart failure patients with preexisting worsening renal function. Circ Heart Fail 12：e005552, 2019

16）Hoste EA, et al：Four phases of intravenous fluid therapy；A conceptual model. Br J Anaesth 113：740-747, 2014