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(Circulation. 2008;117:975-983.)
© 2008 American Heart Association, Inc.

New Drugs and Technologies

Contemporary Trends in the Pharmacological and Extracorporeal Management of Heart Failure

A Nephrologic Perspective

Amir Kazory, MD; Edward A. Ross, MD

From the Division of Nephrology, Hypertension, and Transplantation, University of Florida, Gainesville.

Correspondence to Edward A. Ross, MD, Division of Nephrology, Hypertension, and Transplantation, University of Florida, Box 100224, 1600 SW Archer Rd, Room CG-98, Gainesville, FL 32610-0224. E-mail rossea{at}medicine.ufl.edu

Heart failure and chronic kidney disease share a number of risk factors and pathophysiological pathways. These 2 pathological processes coexist in large numbers of patients. Whereas the presence of chronic kidney disease in patients with heart failure adversely influences their survival, cardiovascular disease is the major cause of mortality in individuals with chronic kidney disease. The management of heart failure by cardiologists has recently expanded from pharmacological treatment to extracorporeal strategies; the interaction between (and concurrent use of) these approaches traditionally has been part of nephrology care and training. The purpose of this review is to explore these management strategies from a nephrologic standpoint and cover the pathophysiology of diuretic resistance, new pharmaceutical strategies to induce natriuresis or aquaresis, and the physiological basis and theoretical advantages of fluid removal by nontraditional peritoneal or hemofiltration approaches. This review also focuses on the technical features, safety, and potential risks of dedicated ultrafiltration devices that do not require dialysis staff or facilities and that are now readily available to nonnephrologists.

Key Words: diuretics • extracorporeal circulation • heart failure • natriuretic peptides • pharmacology