RoleoftheKidney inthePathogenesis ofCongestive HeartFailure

"Thereisan arrangementintheliving being, a kindofregulated activity, whichmust never beneglected, because itisintruththemost striking characteristic oftheliving being .. Af FORTUNATELY forthepatient withcongestive heartfailure, theefficacy ofthe treatment ofthisdisease hassurpassed our knowledge ofitspathologic physiology. Thus, useful lives havebeenprolonged despite only fragmentary information concerning the mechanisms responsible forthesymptomsof thedisease, orthemechanisms ofaction ofthe therapeutic regimens andagentsemployed. Thesalutory effects ofbedrestanddigitalis havelongbeenknown.Morerecently, reductioninsalt intake coupled withpotent diureticshasproduced adramatic improvement in theoutlook ofthepatient withedemaand ascites. Thepotency ofthenewerdiuretic agents haslednaturally toa preoccupation withtheroleofthekidney influid retention, asdidWithering's original observations onthe diuretic action ofthefoxglove.2 However, this preoccupation withthelatestages ofthe disease, andwiththeroleofthekidney inthe production ofedemaincongestive heartfailure,hastended toobscure theevidence that changes insodium andwatermetabolism are present inheartdisease ata timewhenthe cardiovascular systemisonlyslightly impaired.3 Thesesmall, important, andearly alterations aredifficult toevaluate inthe humanpatient, since detailed adequately controlled experiments inthenormalstate are usually lacking inthosepatients withheart disease whomthephysician wishes tostudy. Norisitfeasible todorepeated studies inthe sameindividual fromthemomentthatcardiac abnormalities aredetected tothetimethat