Connotation of Shenqi Pills based on severe cases in cardiovascular care unit and modern pathophysiological mechanism and application of Shenqi Pills for heart failure, renal failure, cardiorenal syndrome, and diuretic resistance in critical care medicine / 中国中药杂志

Shenqi Pills, first recorded in Essentials from the Golden Cabinet(Jin Kui Yao Lue) from ZHANG Zhong-jing in Han dynasty, have the effect of warming and tonifying the kidney Qi and are mainly used for the treatment of insufficiency of kidney Qi and kidney Yang. According to modern medicine, kidney Qi involves heart function, kidney function, immune function, and so on. The clinical indications of Shenqi Pills include kidney deficiency, abnormal fluid, and abnormal urination, and the last one is classified into little urine, much urine, and dysuria. In clinical settings, Shenqi Pills can be applied for the treatment of heart failure, renal failure, cardiorenal syndrome, and diuretic resistance, as well as endocrine, urological, orthopedic, and other chronic degenerative diseases. Shenqi Pills are ideal prescriptions for the weak constitution and emergency treatment. It is of great value and significance to carry out in-depth research on the connotation of the classic articles by integrating TCM and western medicine based on "pathogenesis combined with pathology and drug properties combined with pharmacology".

Estado del arte del síndrome cardiorrenal, ventajas y limitaciones de las terapias conocidas / State of the art of cardiorenal syndrome, advantages and limitations of known therapies

Resumen Las interacciones entre las enfermedades cardiacas y las renales se han clasificado como síndromes cardiorrenales. La clasificación actual incluye cinco subtipos: insuficiencia cardiaca aguda que conduce a insuficiencia renal aguda (tipo 1), insuficiencia cardiaca crónica que conduce a insuficiencia renal (tipo 2), lesión renal aguda que conduce a insuficiencia cardiaca (tipo 3), enfermedad renal crónica que conduce a insuficiencia cardiaca (tipo 4) y afecciones sistémicas que conducen a insuficiencia cardiaca y renal (tipo 5) (tabla 1)1,2. En esta revisión discutimos la definición, la clasificación y la fisiopatología del síndrome cardiorrenal, enfocándonos en el manejo en fases agudas y su recuperación, al exponer la evidencia actualmente disponible de los diuréticos y la ultrafiltración, con el objetivo de intervenir de manera oportuna a nuestros pacientes al conocer las ventajas y las limitaciones de cada una de las estrategias de manejo en aras de reducir el riesgo de eventos clínicos, rehospitalización y muerte.

Abstract Interactions between heart and kidney disease have been classified as cardiorenal syndromes. The current classification includes five subtypes, which are: acute heart failure leading to acute kidney failure (type 1), chronic heart failure leading to kidney failure (type 2), acute kidney injury leading to heart failure (type 3), chronic kidney disease leading to heart failure (type 4) and systemic conditions leading to heart and kidney failure (type 5) (table 1)1,2. In this review, we discuss the definition, classification, pathophysiology, focusing on acute phases treatment and its recovery, exposing the actual evidence for diuretics and ultrafiltration in order to intervene in a timely manner, pointing out the main advantages and limitations of each of the available strategies of treatment in order to reduce the risk of clinical events, re-hospitalization and death.

Efficacy of blood purification therapy on diuretic resistance in patients withnephrotic edema / 实用医学杂志

Objective To investigate the efficacy and safety of blood purification therapy in the treatment of diuretic resistance in patients with nephrotic edema.Methods 40 cases of primary nephrotic syndrome with diuretic resistance in our hospital were randomly divided into hemodialysis (HD) group and continuous blood purification (CVVH) group and each group were 20 cases.All the patients were given basic treatment (lipid modulation,anticoagulation and glucocorticoid) and the observation time was 4 weeks.The changes of biochemical indexes (24 h urine protein,plasma albumin,serum urea nitrogen and serum creatinine) were observed before and after treatment in two groups.In addition,the complications of four groups were recorded.Results After blood purification treatment,urinary volume of two groups were significantly increased,the quantity of 24 h urinary protein and serum albumin were significantly improved,levels of serum urea nitrogen and serum creatinine were significantly decreased.The differences were statistically significant (P ＜ 0.05 or P ＜ 0.01).Compared with HD group,the urine volume increased more obviously in CVYH group after 2 weeks' treatment (P ＜ 0.05).The same time,24 h urinary protein was reduced and plasma albumin was improved more significantly (P ＜ 0.05),levcls of serum urea nitrogen and serum creatinine were not differ between the two groups (P ＞ 0.05).There was no difference in urine volume and renal function between the two groups (P ＞ 0.05) after 4 weeks' treatment.24 h urinary protein was significantly decreased and serum albumin was significantly higher than HD group (P ＜ 0.05).There were no serious complications in the two groups.Conclusion Blood purification in the treatment of diuretic resistance in patients with nephrotic edema is safe and effective.Continuous blood purification treatment can effectively alleviate nephrotic edema with diuretic resistance,promote the recovcry of renal function and improve the prognosis of kidney disease.

Study in the protective role of continuous veno-venous hemofiltration in patients with diuretic-ineffective cardiac insufficiency / 中华急诊医学杂志

Objective To study the protective role of continuous veno-venous hemofiltration (CVVH) in cardiac insufficiency refractory to diuretic therapy after acute myocardial infarction.Methods A total of 104 acute myocardial infarction patients admitted from march 2012 to march 2016 were recruited.According to their wishes,the patients were divided into two groups,continuous veno-venous hemofiltration combined with routine therapy as experimental group (n =52) and conventional treatment as control group (n =52).Mortality rate within one month,the mean length of ICU stay,the mean length of hospital stay,ventilator usage and urine output volume were documented.Then the difference in BW between pre-and post-treatment was determined for evaluation of fluid retention,and blood plasma C-reactive protein (ΔCRP),interleukin 6 (ΔIL-6),interleukin 8 (ΔIL-8),tumor necrosis factor-α (ΔTNF-α) and left ventricular ejection fraction (ΔLVEF) were measured and calculated.A multiple linear regression model to predict ΔLVEF was established.Data recorded at different intervals in the same group were analyzed by ANOVA.Data of the monitoring biomarkers,the mean length of ICU stay,the mean length of hospital stay of two groups were recorded at the same given intervals were analyzed by t test.Data of mortality rate within one month,drugs and ventilator usage in two groups were analyzed by x2 test.P value less than 0.05 was considered statistically significant.Results There were significant differences in mortality rate within one month,the mean length of ICU stay,the mean length of hospital stay,and the duration of ventilator usage between the two groups (P ＜ 0.05).Total volume of fluid output (urine and ultrafiltration volume) was higher in experiment group than that in control group in 48 hours after the treatment (P ＜ 0.01).The levels of CRP,IL-6,IL-8 and TNF-α decreased significantly (P ＜ 0.05) in experiment group after treatment but not in control group (P ＞ 0.05) as compared with those before the treatment.BW was decreased and LVEF was increased in both groups after treatment (P ＜ 0.05) compared with those before the treatment.Levels of CRP,IL-6,IL-8 and TNF-α were lower in experiment group than those in control group after treatment (P ＜ 0.05).BW was meagerly lower and LVEF was meagerly higher in experiment group than those in control group without statistical significance (P ＞ 0.05).However,the degrees of ΔLVEF andΔBW were greater in experiment group than those in control group (P ＜ 0.01).In experiment group,significantly positive correlations were found among ΔBW,ΔCRP,ΔIL-6,ΔIL-8,ΔTNF-α and ΔLVEF (P ＜0.05).Multiple linear regression analyses showed that ΔBW and ΔTNF-α were the independent factors forΔLVEF and ΔBW was the main independent factor for ΔLVEF in control group.ΔLVEF was positively correlated with ΔBW (P＜0.01) but had no correlation with ΔCRP,ΔIL-6,ΔIL-8 and ΔTNF-α (P ＞0.05).Multiple 1inear regression analyses showed that only ΔBW was the independent factor for ΔLVEF.Conclusion CVVH plays protective role in acute myocardial infarction patients with consequent cardiac insufficiency refractory to diuretic therapy by clearance of inflammatory cytokines and removal of retained fluid,and the removal of retained fluid is the most import mechanism to protect heart function.

Ultrafiltration in patients with decompensated heart failure and diuretic resistance: an Asian centre's experience

<p><b>INTRODUCTION</b>Diuretics are the mainstay of therapy for restoring the euvolaemic state in patients with decompensated heart failure. However, diuretic resistance remains a challenge.</p><p><b>METHODS</b>We conducted a retrospective cohort study to examine the efficacy and safety of ultrafiltration (UF) in 44 hospitalised patients who had decompensated heart failure and diuretic resistance between October 2011 and July 2013.</p><p><b>RESULTS</b>Among the 44 patients, 18 received UF (i.e. UF group), while 26 received diuretics (i.e. standard care group). After 48 hours, the UF group achieved lower urine output (1,355 mL vs. 3,815 mL, p = 0.0003), greater fluid loss (5,058 mL vs. 1,915 mL, p < 0.0001) and greater weight loss (5.0 kg vs. 1.0 kg, p < 0.0001) than the standard care group. The UF group also had a shorter duration of hospitalisation (5.0 days vs. 9.5 days, p = 0.0010). There were no differences in the incidence of 30-day emergency department visits and rehospitalisations for heart failure between the two groups. At 90 days, the UF group had fewer emergency department visits (0.2 vs. 0.8, p = 0.0500) and fewer rehospitalisations for heart failure (0.3 vs. 1.0, p = 0.0442). Reduction in EQ-5D™ scores was greater in the UF group, both at discharge (2.7 vs. 1.4, p = 0.0283) and 30 days (2.5 vs. 0.3, p = 0.0033). No adverse events were reported with UF.</p><p><b>CONCLUSION</b>UF is an effective and safe treatment that can improve the health outcomes of Asian patients with decompensated heart failure and diuretic resistance.</p>

Tolvaptan for treatment of decompensated heart failure patients with diuretic resistance and hyponatremia / 第二军医大学学报

Objective To assess the efficacy and safety of low dose short-term tolvaptan in treatment of decompensated heart failure patients with diuretic resistance and hyponatremia. Methods The clinical data of consecutive patients with decompensated heart failure, who were admitted to Changzheng Hospital from April 2012 to March 2014, were analyzed retrospectively. Patients were assigned to receiving tolvaptan (15 mg/d × 7 d) or standard therapy (including 3%-4% hypertonic saline × 7 d). The efficacy endpoints were heart failure symptoms relief, serum sodium elevation during hospitalization and cardiovascular death at 180 d from discharge. The safety endpoint included adverse effect of thirsty, renal function impairment and symptoms of nervous system. Results A total of 37 patients met the inclusion criteria and were assigned to tolvaptan (n=16) or standard therapy (n=21). There were no significant differences between the 2 groups at baseline. The elevation of serum sodium at day 7, reduction of body weight and NT-proBNP level before discharge, and the ratio of restoration to higher than NYHA class Ⅱin the tolvaptan group were all significantly more than those in the standard therapy group (P<0.05). Tolvaptan, compared with standard therapy, significantly decreased the mean dose of furosemide, serum creatinine elevation and hospital stay (P<0.05), but failed to lower the cardiovascular mortality at 180 d follow-up. Conclusion For Chinese patients with decompensated heart failure with diuretic resistance and hyponatremia, in addition to guideline-recommended therapies for heart failure, low dose short term tolvaptan is associated with more favorable in-hospital effects and less severe adverse effects, but not with long-term cardiovascular mortality.

Application of torsemide to two dogs with congestive heart failure / 대한수의학회지

An 11-year-old castrated male Maltese weighing 3.6 kg and a 12-year-old intact female Shih-tzu weighing 6.5 kg were admitted to the Veterinary Medical Teaching Hospital of Chungnam National University with decompensatory congestive heart failure. Diuretic resistance was suspected due to long term diuretic therapy with furosemide. However, the patients improved after the furosemide treatment was changed to torsemide, demonstrating the benefits of application of torsemide to treat diuretic resistance caused by long term use of furosemide. These findings suggest that torsemide should be applied for treatment of diuretic resistance caused by long term use of furosemide.

Torsemide: A New Loop Diuretic.

Loop diuretics are often administered to hospitalized patients to augment urinary output. They play an essential role in the treatment of fluid overload in patients of congestive heart failure and chronic renal failure. Torsemide is a new loop diuretic that has revolutionized the therapy of fluid overload disorders. Torsemide has a higher bioavailability, greater potency and longer duration of action than frusemide. Torsemide causes significantly greater diuresis, natriuresis, lesser kaluresis, greater reduction in body weight and improvement in edema and ascites as compared to frusemide.

Mechanisms of Diuretic Resistance and Tolerance / 대한신장학회잡지

Diuretics are natriuretic agents which inhibit sodium reabsorption at their major site of action on the renal tubules and increase the excretion of sodium and combined anions. Increment of urine volume is the secondary to the natriuretic effects. Diuretic resistance occurs that threshold dose of diuretics is higher than that of other patients. It is frequently manifested among the edematous patients such as those with the nephrotic syndrome. Prolonged use of diuretics decreases the natriuretic effect of diuretics, which is called diuretic tolerance. This is important adaptations of distal nephron segment. To elucidate the mechanism of diuretic resistance, 1 mg of bumetanide was given to the nephrotic syndrome(NS) patients group and control group, respectively. The peak plasma concentration was delayed in NS patients. The proportion of urine free bumetanide for 24 hours was 73% in NS patients but 100% in control group. The ratio of urine volume and amount of Na+ and Cl - for 24 hours to the total and free urine bumetanide was decreased in NS patients. The study suggests that pharmacokinetic and pharmacodynamic changes of the diuretics induce the diuretic resistance. To determine the additive diuretic effect of albumin to the action of the furosemide, 160 mg of furosemide was administered intravenously with albumin in NS patients. Simultaneous infusion of albumin and furosemide did not enhance the diuretic effect of furosemide pharmacodynamically and pharmacokinetically. Albumin preinfusion 30 minutes before furosemide administration potentiates the diuresis, but natiuresis and pharmacokinetics were not changed. Semiquantitative immunoblotting of rat kidneys was carried out to investigate whether chronic diuretics adminstration induces changes in the abundance of Na+ transporters in distal nephron. Furosemide infusion increased cortical and outer medullary abundances of Na+-Cl- cotransporter(TSC) and all 3 subunits of the epithelial sodium channel(ENaC). Hydrochlorothiazide infusion increased abundances of some kinds of subunits of ENaC. These increases in the abundances of Na+ transporters may account for the generation of diuretic tolerance.These data suggest that to overcome the diuretic resistance or tolerance, diuretic dose increment over the threshold level and more frequent administration of the diuretics are recommended. Diuretic combinations are also proposed. Addition of albumin to augment the diuretics effect ought to be considered cautiously.