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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">Levosimendan is a relatively new inotropic agent&#44; used in cases of decompensated heart failure&#44; which has shown&#44; in some reported cases&#44; improvement in the patients&#191; renal function&#46;</p><p class="elsevierStylePara">We report the case of a 70-year-old male patient&#44; monitored for grade III chronic kidney disease with no affiliated aetiology&#44; with CCr of 45ml&#47;min in the last examination&#46; His medical history includes the following&#58; monoclonal gammopathy of an uncertain significance&#59; femoral cutaneous neuropathy&#59; and multifactorial heart failure &#40;ischaemic heart failure&#44; non-ischaemic dilated cardiomyopathy&#44; moderate pulmonary hypertension&#44; heart disease with a pacemaker&#41;&#44; with several episodes of decompensation causing his hospitalisation&#46; He followed a regular treatment of Acenocoumarol&#44; Carvedilol&#44; Enalapril&#44; Torasemide&#44; Digoxin&#44; Atorvastatin&#44; Alopurinol&#44; Folic acid&#44; Vitamin B12&#44; Ferrous sulphate and Neorecormon&#46;</p><p class="elsevierStylePara">His hospitalisation was caused by a new decompensation of his heart failure&#44; a deterioration of his dyspnoea&#44; important levels of orthopnoea&#44; episodes of paroxysmal nocturnal dyspnoea&#44; ascites and oedematisation of limbs with a progressive decrease of diuresis&#46; Moreover&#44; he mentioned profuse haemorrhage due to a haemorrhoidal condition&#44; and the examination confirmed a deterioration of the renal function&#46;</p><p class="elsevierStylePara">During examination the patient experienced tachypnoea&#44; with labial cyanosis&#44; jugular ingurgitation and bad tolerance to the supine position&#46; BP&#58; 116&#47;54&#46; The cardiopulmonary auscultation showed rhythmic tones at 69 bpm&#44; with R3 and a systolic heart murmur of 1&#47;6 in the mitral and aortic areas&#59; presence of rhonchi and diffuse wheezing&#44; with crepitations in both pulmonary bases&#46; The patient showed signs of hepatomegaly and inferior limbs oedematised until the knee with fovea&#46; Diuresis remained at a daily level of around 2 litres&#46; The examination revealed a deterioration of his renal function with Cr 3mg&#47;dl&#44; CCr estimated at&#58; 24ml&#47;min &#40;baseline levels of 2mg&#47;dl and 45ml&#47;min&#44; respectively&#41;&#46; Urea 173mg&#47;dl&#44; Na 132mg&#47;dl and K 6&#46;4mg&#47;dl&#46; Hb&#58; 5&#46;7g&#47;dl&#44; requiring blood transfusion&#46; The ECG showed a biventricular pacemaker rhythm at 70 bpm&#44; and the thorax X-ray revealed an image of severe cardiomegaly with signs of vascular redistribution&#46; Colonoscopy was carried out with anal fissure being the sole finding&#46; The ECG showed severely dilated left cavities with severe global hypokinesia and FE estimated at 21&#37;&#46;</p><p class="elsevierStylePara">Intensive diuretic treatment was carried out with a poor response&#44; leading to the decision to treat with Levosimendan in perfusion at a dose of 12&#46;5 mg IV for 24 hours&#46; The patient progressed satisfactorily for his congestive condition&#58; dyspnoea disappeared and renal function improved&#44; showing creatinine figures of 1&#46;8 mg&#47;dl at discharge&#46;</p><p class="elsevierStylePara">The patient was examined after 6 months&#44; and the continuing improvement of his renal function was confirmed&#58; Cr 1&#46;5mg&#47;dl&#44; CCr 52ml&#47;min&#46;</p><p class="elsevierStylePara">In the clinical management of AKD&#44; the fundamental factors are to maintain euvolaemia&#44; an effective cardiac output and adequate pressure of the renal perfusion&#46; For this reason&#44; we apply volume expansion&#44; which is switched to the administration of vasopressors &#40;dopamine and noradrenaline being the first choice&#41; when it proves to be inadequate in restoring blood pressure&#46; When peripheral hypoperfusion is caused by a condition of acute heart failure due to systolic dysfunction&#44; the positive inotropic medicines with a vasodilatory effect through IV are a therapeutic option&#59; Levosimendan being at the top of this group of drugs&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">This drug has a triple action mechanism&#58; first&#44; it improves cardiac contractility by sensitising calcium with troponin C&#46; On the other hand&#44; it produces arterial and venous vasodilatation by activating the potassium channels sensitive to adenosine triphosphate &#40;ATP&#41; of the plain vascular muscle fibre and&#44; lastly&#44; it produces phosphodiesterase III inhibitors&#46;<span class="elsevierStyleSup">2</span> It is administered through IV and it is initially prescribed at a loading dose of 6-12&#956;&#47;kg for 10 minutes&#44; with a subsequent dose of 0&#46;05-0&#46;2&#956;-7 kg&#47;min for 24 hours&#46; Its main side effects are owed to its vasodilatory effect&#58; cephalalgia&#44; nausea&#44; hypotension&#44; etc&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Various studies exist in the literature&#44; in which Levosimendan is used in patients hospitalised with heart failure&#46;This confirms its beneficial effect for renal function&#44; including its comparison with the effects of other types of medicine&#44; such as dobutamine&#44; while it maintains its effect during the 3 monitoring months&#44; as in our case&#46;<span class="elsevierStyleSup">4&#44;5</span></p><p class="elsevierStylePara">Therefore&#44; to conclude&#44; Levosimendan is a new alternative therapy in the treatment of decompensated heart failure with a secondary renal failure&#44; improving the parameters of renal function and maintaining this effect for several months&#46; </p>"
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Use of Levosimendan in acute heart failure and its effect on renal function
Utilidad de Levosimendán en insuficiencia cardíaca aguda y su efecto sobre la función renal
Aurora Polo Moyanoa, R.. López Hidalgoa, D.. Barreda Grandea, S.. Cerezo Moralesa
a Servicio de Nefrología, Hospital Universitario San Cecilio, Granada, Granada, España,
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    "textoCompleto" => "<p class="elsevierStylePara">Dear Editor&#44;</p><p class="elsevierStylePara">Levosimendan is a relatively new inotropic agent&#44; used in cases of decompensated heart failure&#44; which has shown&#44; in some reported cases&#44; improvement in the patients&#191; renal function&#46;</p><p class="elsevierStylePara">We report the case of a 70-year-old male patient&#44; monitored for grade III chronic kidney disease with no affiliated aetiology&#44; with CCr of 45ml&#47;min in the last examination&#46; His medical history includes the following&#58; monoclonal gammopathy of an uncertain significance&#59; femoral cutaneous neuropathy&#59; and multifactorial heart failure &#40;ischaemic heart failure&#44; non-ischaemic dilated cardiomyopathy&#44; moderate pulmonary hypertension&#44; heart disease with a pacemaker&#41;&#44; with several episodes of decompensation causing his hospitalisation&#46; He followed a regular treatment of Acenocoumarol&#44; Carvedilol&#44; Enalapril&#44; Torasemide&#44; Digoxin&#44; Atorvastatin&#44; Alopurinol&#44; Folic acid&#44; Vitamin B12&#44; Ferrous sulphate and Neorecormon&#46;</p><p class="elsevierStylePara">His hospitalisation was caused by a new decompensation of his heart failure&#44; a deterioration of his dyspnoea&#44; important levels of orthopnoea&#44; episodes of paroxysmal nocturnal dyspnoea&#44; ascites and oedematisation of limbs with a progressive decrease of diuresis&#46; Moreover&#44; he mentioned profuse haemorrhage due to a haemorrhoidal condition&#44; and the examination confirmed a deterioration of the renal function&#46;</p><p class="elsevierStylePara">During examination the patient experienced tachypnoea&#44; with labial cyanosis&#44; jugular ingurgitation and bad tolerance to the supine position&#46; BP&#58; 116&#47;54&#46; The cardiopulmonary auscultation showed rhythmic tones at 69 bpm&#44; with R3 and a systolic heart murmur of 1&#47;6 in the mitral and aortic areas&#59; presence of rhonchi and diffuse wheezing&#44; with crepitations in both pulmonary bases&#46; The patient showed signs of hepatomegaly and inferior limbs oedematised until the knee with fovea&#46; Diuresis remained at a daily level of around 2 litres&#46; The examination revealed a deterioration of his renal function with Cr 3mg&#47;dl&#44; CCr estimated at&#58; 24ml&#47;min &#40;baseline levels of 2mg&#47;dl and 45ml&#47;min&#44; respectively&#41;&#46; Urea 173mg&#47;dl&#44; Na 132mg&#47;dl and K 6&#46;4mg&#47;dl&#46; Hb&#58; 5&#46;7g&#47;dl&#44; requiring blood transfusion&#46; The ECG showed a biventricular pacemaker rhythm at 70 bpm&#44; and the thorax X-ray revealed an image of severe cardiomegaly with signs of vascular redistribution&#46; Colonoscopy was carried out with anal fissure being the sole finding&#46; The ECG showed severely dilated left cavities with severe global hypokinesia and FE estimated at 21&#37;&#46;</p><p class="elsevierStylePara">Intensive diuretic treatment was carried out with a poor response&#44; leading to the decision to treat with Levosimendan in perfusion at a dose of 12&#46;5 mg IV for 24 hours&#46; The patient progressed satisfactorily for his congestive condition&#58; dyspnoea disappeared and renal function improved&#44; showing creatinine figures of 1&#46;8 mg&#47;dl at discharge&#46;</p><p class="elsevierStylePara">The patient was examined after 6 months&#44; and the continuing improvement of his renal function was confirmed&#58; Cr 1&#46;5mg&#47;dl&#44; CCr 52ml&#47;min&#46;</p><p class="elsevierStylePara">In the clinical management of AKD&#44; the fundamental factors are to maintain euvolaemia&#44; an effective cardiac output and adequate pressure of the renal perfusion&#46; For this reason&#44; we apply volume expansion&#44; which is switched to the administration of vasopressors &#40;dopamine and noradrenaline being the first choice&#41; when it proves to be inadequate in restoring blood pressure&#46; When peripheral hypoperfusion is caused by a condition of acute heart failure due to systolic dysfunction&#44; the positive inotropic medicines with a vasodilatory effect through IV are a therapeutic option&#59; Levosimendan being at the top of this group of drugs&#46;<span class="elsevierStyleSup">1</span></p><p class="elsevierStylePara">This drug has a triple action mechanism&#58; first&#44; it improves cardiac contractility by sensitising calcium with troponin C&#46; On the other hand&#44; it produces arterial and venous vasodilatation by activating the potassium channels sensitive to adenosine triphosphate &#40;ATP&#41; of the plain vascular muscle fibre and&#44; lastly&#44; it produces phosphodiesterase III inhibitors&#46;<span class="elsevierStyleSup">2</span> It is administered through IV and it is initially prescribed at a loading dose of 6-12&#956;&#47;kg for 10 minutes&#44; with a subsequent dose of 0&#46;05-0&#46;2&#956;-7 kg&#47;min for 24 hours&#46; Its main side effects are owed to its vasodilatory effect&#58; cephalalgia&#44; nausea&#44; hypotension&#44; etc&#46;<span class="elsevierStyleSup">3</span></p><p class="elsevierStylePara">Various studies exist in the literature&#44; in which Levosimendan is used in patients hospitalised with heart failure&#46;This confirms its beneficial effect for renal function&#44; including its comparison with the effects of other types of medicine&#44; such as dobutamine&#44; while it maintains its effect during the 3 monitoring months&#44; as in our case&#46;<span class="elsevierStyleSup">4&#44;5</span></p><p class="elsevierStylePara">Therefore&#44; to conclude&#44; Levosimendan is a new alternative therapy in the treatment of decompensated heart failure with a secondary renal failure&#44; improving the parameters of renal function and maintaining this effect for several months&#46; </p>"
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