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NephMadness 2022: Cardiorenal Syndrome

Classically, the pathophysiology of cardiorenal syndrome was thought of as decreasing cardiac index leading to poor forward flow and subsequent reduced kidney perfusion/kidney dysfunction. However, in recent years, it has become apparent that reduced cardiac index/forward flow is not the primary driver of kidney dysfunction (Hanberg 2016). In fact, most patients coming in with decompensated heart failure, even those with reduced ejection fraction, have preserved cardiac indices. Instead, it has become increasingly recognized that elevated venous pressure/ venous congestion plays a critical role in the pathophysiology of cardiorenal syndrome.

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 Cardiorenal Syndrome A Cardiologist's Perspective of Pathophysiology

The cardiorenal syndrome has recently been defined as “disorders of the heart and kidney whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other.” The syndrome is extremely common and independently associated with poor clinical outcomes. However, no pharmacological therapy has been shown to improve its outcomes. Unfortunately, the mechanisms that initiate the development of renal dysfunction in heart failure are still debated.

 Cardiorenal Syndrome Revisited

Cardiorenal syndromes have been categorized into 5 clinical subtypes based on which organ is perceived to be the primary precipitant of the vicious and interrelated cycle of declining function in both organs. This clinical classification has broadened interest in cardiorenal interactions, but it is merely descriptive, does not rely on or inform predominant pathophysiology, and has produced little change in either practice or the research agenda.

Previously Featured

Cardiorenal syndrome

Cardiorenal syndrome used to signify the unique cause of acute kidney injury where the decrease in function is due to apparent volume depletion in a patient that obviously overloaded. It named the only scenario where acute kidney injury responded to diuresis. It was unique and specific. Ronco comes along and says, yes I like your version of cardiorenal syndrome so I will make it type 1 in my new all purpose definition of cardiorenal syndrome. Now whenever there is cardiac dysfunction and simultaneous kidney dysfunction we can just call it cardiorenal syndrome.

Cardiorenal Syndrome and Heart Failure

Types of cardiorenal syndrome. Cardiorenal syndrome can be seen in an acute setting, such as when the hemodynamic changes of heart failure lead to acute kidney injury (type 1). Acute kidney injury such as glomerulonephritis (GN) can lead to heart failure (HF) or myocardial ischemia (type 3). The chronic hemodynamics of heart failure can also lead to chronic kidney disease (type 2), or chronic kidney disease (CKD) can lead to heart failure, commonly with preserved ejection fraction (HFpEF, type 4). Systemic conditions such as sepsis or diabetes can also cause simultaneous heart and kidney failure (type 5).

Cardiorenal Syndrome in the Hospital

Share Favorites Permissions CRITICAL CARE NEPHROLOGY AND ACUTE KIDNEY INJURY Cardiorenal Syndrome in the Hospital McCallum, Wendy; Sarnak, Mark J. Author Information Clinical Journal of the American Society of Nephrology 18(7):p 933-945, July 2023. | DOI: 10.2215/CJN.0000000000000064 FREE Metrics Abstract The cardiorenal syndrome refers to a group of complex, bidirectional pathophysiological pathways involving dysfunction in both the heart and kidney. Upward of 60% of patients admitted for acute decompensated heart failure have CKD, as defined by an eGFR of <60 ml/min per 1.73 m2. CKD, in turn, is one of the strongest risk factors for mortality and cardiovascular events in acute decompensated heart failure.

Cardiorenal Syndrome: A Literature Review

The clinical importance of these interactions is evident in the changes observed in hemodynamic factors, neurohormonal markers, and inflammatory processes. Identifying and understanding biomarkers associated with CRS is valuable for early detection and enabling intervention before significant organ dysfunction occurs.

Cardiorenal Syndrome: Classification, Pathophysiology, Diagnosis, and Treatment Strategies: A Scientific Statement From the American Heart Association

The nuanced and highly interdependent relationship between the kidney and the heart was described as early as 1836 by Robert Bright, who outlined the significant cardiac structural changes seen in patients with advanced kidney disease. Since then, numerous advances have been made in summarizing the cardiorenal link in terms of hemodynamic phenotypes, pathophysiology, therapeutic options, and clinical outcomes.

Emerging Treatments of Cardiorenal Syndrome: An Update on Pathophysiology and Management

Cardiorenal syndrome refers to combined cardiac and renal dysfunction that adversely impacts both organs and is also associated with severe clinical outcomes. The pathophysiology is believed to be multifactorial and complex. Increased central venous pressure and intra-abdominal pressure, overactivation of the Renin-Angiotensin-Aldosterone System (RAAS), systemic illnesses like sepsis, amyloidosis, diabetes are important factors in developing the cardiorenal syndrome.

From cardiorenal syndromes to cardionephrology: a reflection by nephrologists on renocardiac syndromes

Cardiorenal syndromes (CRS) are broadly defined as disorders of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other. CRS are currently classified into five categories, mostly based on disease-initiating events and their acuity or chronicity.

New insights into the pathophysiological mechanisms underlying cardiorenal syndrome

Communication between the heart and kidney occurs through various bidirectional pathways. The heart maintains continuous blood flow through the kidney while the kidney regulates blood volume thereby allowing the heart to pump effectively. Cardiorenal syndrome (CRS) is a pathologic condition in which acute or chronic dysfunction of the heart or kidney induces acute or chronic dysfunction of the other organ

Studies show that patients with cardio-renal-metabolic conditions benefit from holistic care

While the heart and kidneys serve different functions in the body, they have a profound impact on one another. In fact, 94% of people with type 2 diabetes presented with at least one cardiovascular or renal comorbidity. This overlap in C-R-M conditions underscores the need for a multidisciplinary approach to care.

Resources

Life in the Fastlane

Cardiorenal syndromes (CRS) are disorders of the heart and kidneys whereby acute or long-term dysfunction in one organ may induce acute or long-term dysfunction of the other. CRS is characterised by the triad of concomitant decreased kidney function, therapy-resistant heart failure with congestion (ie, diuretic resistance), and worsening kidney function during heart failure therapy

StatPearls

Cardiorenal syndrome includes multiple subtypes based on underlying pathology and chronicity. Each subtype involves unique pathophysiology, and thus, the management strategy for each subtype is different management strategies.