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cardiorenal syndrome

renal insufficiency in the setting of acute heart failure Classification: 1) acute heart failure leading to acute renal failure 2) chronic heart failure leading to chronic renal failure 3) acute renal failure leading to acute heart failure 4) chronic renal failure leading to chronic heart failure, coronary artery disease or cardiac arrhythmias 5) systemic conditions leading to simultaneous heart failure & renal failure (i.e. sepsis) Etiology: - primarily seen in HFrEF Pathology: - elevated renal vein pressure -> distended renal venules -> increased renal tubule pressure & backleak Clinical manifestations: - diuretic-resistant congestive heart failure - acute renal failure - worsening renal function with heart failure treatment [1] Laboratory: - serum creatinine commonly increases with treatment of hypervolemia until fluid balance is achieved - serum sodium may be low - urine sodium < 20 meq/L with: - sodium retention by the kidneys, diuretic resistance Complications: - mainstay of treatment for volume overload in patients with acute heart failure, diuretics, can worsen renal function Management: - general measures (old recommendations) - discontinue diuretics - sodium restriction - treatment with vasocontrictors - infusion of albumin [1] - high-dose intravenous diuretics may be needed to treat acute kidney injury due to cardiorenal syndrome [1] - loop diuretic + thiazide diuretic for volume overload - ultrafiltration may be useful in patients who have not responded (with diuresis) to diuretics [1] - evidence does not support the use of ultrafiltration over intensive diuretic management for patients with cardiorenal syndrome (MKSAP20) [1] - OpenEvidence would disagree - do not increase beta-blocker during acute heart failure - nesiritide of no benefit - aortic valve replacement can improve renal function in patients with aortic valve disease [6]

General

syndrome acute heart failure (AHF) acute renal failure (ARF)

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021. - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  2. Bart BA et al. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med 2012 Nov 6; PMID: 23131078 http://www.nejm.org/doi/full/10.1056/NEJMoa1210357
  3. Ronco C, Haapio M, House AA, Anavekar N, Bellomo R. Cardiorenal syndrome. J Am Coll Cardiol. 2008 Nov 4;52(19):1527-39. PMID: 19007588
  4. Bock JS, Gottlieb SS Cardiorenal syndrome: new perspectives. Circulation. 2010 Jun 15;121(23):2592-600 PMID: 20547939
  5. Verbrugge FH, Grieten L, Mullens W. Management of the cardiorenal syndrome in decompensated heart failure. Cardiorenal Med. 2014 Dec;4(3-4):176-88. Review. PMID: 25737682 Free PMC Article
  6. Witberg G, Steinmetz T, Landes U et al Change in Kidney Function and 2-Year Mortality After Transcatheter Aortic Valve Replacement. JAMA Netw Open. 2021;4(3):e213296. March 26 PMID: 33769507 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2777870 - Galper BZ Can Transcatheter Aortic Valve Replacement Cure Cardiorenal Syndrome? JAMA Netw Open. 2021;4(3):e213753. March 26 PMID: 33769503 https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2777866
  7. Rangaswami J, Bhalla V, Blair JEA, et al; American Heart Association Council on the Kidney in Cardiovascular Disease and Council on Clinical Cardiology. Cardiorenal syndrome: classification, pathophysiology, diagnosis, and treatment strategies: a scientific statement from the American Heart Association. Circulation. 2019;139:e840-78. PMID: 30852913