Clinical Outcomes of Levosimendan Versus Dobutamine Versus Milrinone in Cases With Acute Decompensated Heart Failure With Impaired Renal Function

Inclusion Criteria: * Adult (\>18 years old) patients with ADHF (LVEF ≤ 40% documented prior to enrollment) admitted to the ICU with renal impairment (estimated GFR between 30 and 60 mL/min/1.73 m², calculated using the Modification of Diet in Renal Disease Study equation (MDRD equation)) and require inotropic support. Exclusion Criteria: Cases were excluded from the study if they met any of the following criteria: * Age younger than 18 years * Untreated acute HF * Resting heart rate exceeding 120 beats per minute * Recent MI or acute coronary syndrome within the previous two months * Diagnosed pulmonary embolism * Structural cardiac conditions * Known history of kidney disease diagnosed prior to HF * Administration of contrast agents or nephrotoxic drugs within the previous seven days * Severe liver dysfunction (Child C) * Active acute inflammatory or infectious diseases.