Worsening renal function during treatment of acute decompensated heart failure (ADHF) often complicates the treatment course of heart failure. Furthermore, the development of worsening renal function is a strong independent predictor of long-term adverse outcomes. Sometimes referred to as “cardio-renal syndrome,” the definition varies widely, and the overall understanding of pathogenesis is limited. This is likely due to the lack of precision and characterization of renal compromise during treatment of heart failure. Traditionally, impairment of cardiac output and relative under-filling of arterial perfusion has been attributed to the predominant cause. Emerging data has led to a resurgence of interest in the importance of venous congestion and elevated intra-abdominal pressure rather than confining to impaired forward cardiac output as the primary driver of renal impairment. These revived concepts may support the role of novel renal-sparing approaches to salt and water removal and renal preservation, but better ways to distinguish hemodynamic versus other nephrotoxic etiologies are needed.
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