Elsevier

Journal of Cardiac Failure

Volume 18, Issue 12, December 2012, Pages 930-938
Journal of Cardiac Failure

Review Article
Congestive Renal Failure: The Pathophysiology and Treatment of Renal Venous Hypertension

https://doi.org/10.1016/j.cardfail.2012.10.010Get rights and content

Abstract

Longstanding experimental evidence supports the role of renal venous hypertension in causing kidney dysfunction and “congestive renal failure.” A focus has been heart failure, in which the cardiorenal syndrome may partly be due to high venous pressure, rather than traditional mechanisms involving low cardiac output. Analogous diseases are intra-abdominal hypertension and renal vein thrombosis. Proposed pathophysiologic mechanisms include reduced transglomerular pressure, elevated renal interstitial pressure, myogenic and neural reflexes, baroreceptor stimulation, activation of sympathetic nervous and renin angiotensin aldosterone systems, and enhanced proinflammatory pathways. Most clinical trials have addressed the underlying condition rather than venous hypertension per se. Interpreting the effects of therapeutic interventions on renal venous congestion are therefore problematic because of such confounders as changes in left ventricular function, cardiac output, and blood pressure. Nevertheless, there is preliminary evidence from small studies of intense medical therapy or extracorporeal ultrafiltration for heart failure that there can be changes to central venous pressure that correlate inversely with renal function, independently from the cardiac index. Larger more rigorous trials are needed to definitively establish under what circumstances conventional pharmacologic or ultrafiltration goals might best be directed toward central venous pressures rather than left ventricular or cardiac output parameters.

Section snippets

Pressure-Related Effects

Much research has turned from pressure-related and receptor pathways resulting from “forward” HF to those originating from “backward” HF. An isolated rise in renal venous pressure would lower the arteriovenous pressure gradient across the kidney, decrease the renal blood flow, and lower the transglomerular pressure gradients; however, the importance of intrarenal compensatory mechanisms were highlighted when blood flow was experimentally maintained by changes in arterial perfusion or pressure.4

HF and the Cardiorenal Syndrome

Although the renal dysfunction associated with HF has traditionally been attributed to impaired cardiac output and kidney hypoperfusion, this relationship may not hold true across large cohorts of patients. For example, using the ADHERE (Acute Decompensated Heart Failure National Registry) database of 118,465 decompensated HF admissions, Heywood et al were not able to show an association between left ventricular systolic dysfunction and renal impairment.26 Many recent trials have raised the

Treatment of Renal Venous Hypertension and Congestion

In light of the complex pathophysiology, crafting patient care guidelines that incorporate measures of both renal venous hypertension and left ventricular function is difficult and remains controversial. The frequent discordance between the cardiac index and right-sided pressures across the various cardiac disease entities (eg, with right, left, or biventricular dysfunction) might explain why in Mullins et al’s series43 the elevation in right atrial pressure at the time of acutely decompensated

Conclusion

Longstanding observations of the adverse renal effects from venous hypertension have been explained by multiple pathophysiologic mechanisms, ranging from direct pressure to baroreceptor, neural, cytokine, systemic, and local hormonal factors. Relevant clinical entities include the cardiorenal syndrome in congestive HF, disorders (eg, renal, hepatic, or vena caval) of venous pressure or thromboses, and intra-abdominal hypertension. Renal congestion may also be an integral consequence of acute

Disclosures

None.

References (67)

  • C.S. Wilcox et al.

    Na+, K+, and BP homeostasis in man during furosemide: effects of prazosin and captopril

    Kidney Int

    (1987)
  • W. Mullens et al.

    Elevated intra-abdominal pressure in acute decompensated heart failure: a potential contributor to worsening renal function?

    J Am Coll Cardiol

    (2008)
  • R.F. Bonfim et al.

    Effect of hemodialysis on intra-abdominal pressure

    Clinics (Sao Paulo)

    (2007)
  • G. Marenzi et al.

    Circulatory response to fluid overload removal by extracorporeal ultrafiltration in refractory congestive heart failure

    J Am Coll Cardiol

    (2001)
  • G.C. Marenzi et al.

    Ultrafiltration in moderate heart failure. Exercise oxygen uptake as a predictor of the clinical benefits

    Chest

    (1995)
  • P. Agostoni et al.

    Sustained improvement in functional capacity after removal of body fluid with isolated ultrafiltration in chronic cardiac insufficiency: failure of furosemide to provide the same result

    Am J Med

    (1994)
  • K.V. Liang et al.

    Use of a novel ultrafiltration device as a treatment strategy for diuretic resistant, refractory heart failure: initial clinical experience in a single center

    J Card Fail

    (2006)
  • M.R. Costanzo et al.

    Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure

    J Am Coll Cardiol

    (2007)
  • M. Nakayama et al.

    Novel therapeutic option for refractory heart failure in elderly patients with chronic kidney disease by incremental peritoneal dialysis

    J Cardiol

    (2010)
  • F.R. Winton

    The influence of venous pressure on the isolated mammalian kidney

    J Physiol

    (1931)
  • M.H. Maxwell et al.

    Renal venous pressure in chronic congestive heart failure

    J Clin Invest

    (1950)
  • J.D. Firth et al.

    Raised venous pressure: a direct cause of renal sodium retention in oedema?

    Lancet

    (1988)
  • S.J. Semple et al.

    Effect of increased renal venous pressure on circulatory autoregulation of isolated dog kidneys

    Circ Res

    (1959)
  • C.W. Gottschalk et al.

    Micropuncture study of pressures in proximal tubules and peritubular capillaries of the rat kidney and their relation to ureteral and renal venous pressures

    Am J Physiol

    (1956)
  • M.J. Fiksen-Olsen et al.

    Renal effects of angiotensin II inhibition during increases in renal venous pressure

    Hypertension

    (1992)
  • B. Braam et al.

    Systemic arterial and venous determinants of renal hemodynamics in congestive heart failure

    Heart Fail Rev

    (2012)
  • U. Abildgaard et al.

    Renal vascular adjustments to partial renal venous obstruction in dog kidney

    Circ Res

    (1987)
  • R. Jalan et al.

    Reduction in renal blood flow following acute increase in the portal pressure: evidence for the existence of a hepatorenal reflex in man?

    Gut

    (1997)
  • S.M. Hamza et al.

    Splenorenal reflex modulates renal blood flow in the rat

    J Physiol

    (2004)
  • K. Moncrief et al.

    Splenic reflex modulation of central cardiovascular regulatory pathways

    Am J Physiol Regul Integr Comp Physiol

    (2007)
  • G. Clausen et al.

    Myogenic vasoconstriction in the rat kidney elicited by reducing perirenal pressure

    Acta Physiol Scand

    (1992)
  • P. Morsing et al.

    Renal interstitial pressure and tubuloglomerular feedback control in rats during infusion of atrial natriuretic peptide (ANP)

    Acta Physiol Scand

    (1992)
  • W.D. Blake et al.

    Effect of increased renal venous pressure on renal function

    Am J Physiol

    (1949)
  • Cited by (95)

    View all citing articles on Scopus

    See page 936 for disclosure information.

    View full text