Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point-of-care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors and editors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

Choose from the list below to learn more about subscriptions for a:


Subscribers log in here


Cardiorenal syndrome: Definition, prevalence, diagnosis, and pathophysiology

DEFINITION AND CLASSIFICATION

There are a number of important interactions between heart disease and kidney disease. The interaction is bidirectional, as acute or chronic dysfunction of the heart or kidneys can induce acute or chronic dysfunction in the other organ. The clinical importance of such relationships is illustrated by the following observations:

Mortality is increased in patients with heart failure (HF) who have a reduced glomerular filtration rate (GFR). (See "Cardiorenal syndrome: Prognosis and treatment", section on 'Reduced GFR and prognosis'.)

Patients with chronic kidney disease have an increased risk of both atherosclerotic cardiovascular disease and HF, and cardiovascular disease is responsible for up to 50 percent of deaths in patients with renal failure [1,2]. (See "Chronic kidney disease and coronary heart disease", section on 'Introduction'.)

Acute or chronic systemic disorders can cause both cardiac and renal dysfunction.

The term “cardiorenal syndrome” (CRS) has been applied to these interactions, but the definition and classification have not been clear. A 2004 report from the National Heart, Lung, and Blood Institute defined CRS as a condition in which therapy to relieve congestive symptoms of HF is limited by a decline in renal function as manifested by a reduction in GFR [3]. The reduction in GFR was initially thought to result from a reduction in renal blood flow. However, various studies have demonstrated that cardiorenal interactions occur in both directions and in a variety of clinical settings [4]. (See 'Pathophysiology' below.)

        

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2014. | This topic last updated: Feb 24, 2014.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2014 UpToDate, Inc.
References
Top
  1. United States Renal Data System: Excerpts from the USRDS 2007 annual data report: atlas of end-stage renal disease in the United States. Minneapolis, MN 2007.
  2. Coresh J, Astor BC, Greene T, et al. Prevalence of chronic kidney disease and decreased kidney function in the adult US population: Third National Health and Nutrition Examination Survey. Am J Kidney Dis 2003; 41:1.
  3. http://www.nhlbi.nih.gov/meetings/workshops/cardiorenal-hf-hd.htm (Accessed on September 01, 2010).
  4. Bock JS, Gottlieb SS. Cardiorenal syndrome: new perspectives. Circulation 2010; 121:2592.
  5. Ronco C, Haapio M, House AA, et al. Cardiorenal syndrome. J Am Coll Cardiol 2008; 52:1527.
  6. Smith GL, Lichtman JH, Bracken MB, et al. Renal impairment and outcomes in heart failure: systematic review and meta-analysis. J Am Coll Cardiol 2006; 47:1987.
  7. Ezekowitz J, McAlister FA, Humphries KH, et al. The association among renal insufficiency, pharmacotherapy, and outcomes in 6,427 patients with heart failure and coronary artery disease. J Am Coll Cardiol 2004; 44:1587.
  8. Hillege HL, Girbes AR, de Kam PJ, et al. Renal function, neurohormonal activation, and survival in patients with chronic heart failure. Circulation 2000; 102:203.
  9. Adams KF Jr, Fonarow GC, Emerman CL, et al. Characteristics and outcomes of patients hospitalized for heart failure in the United States: rationale, design, and preliminary observations from the first 100,000 cases in the Acute Decompensated Heart Failure National Registry (ADHERE). Am Heart J 2005; 149:209.
  10. Heywood JT, Fonarow GC, Costanzo MR, et al. High prevalence of renal dysfunction and its impact on outcome in 118,465 patients hospitalized with acute decompensated heart failure: a report from the ADHERE database. J Card Fail 2007; 13:422.
  11. Owan TE, Hodge DO, Herges RM, et al. Secular trends in renal dysfunction and outcomes in hospitalized heart failure patients. J Card Fail 2006; 12:257.
  12. Forman DE, Butler J, Wang Y, et al. Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. J Am Coll Cardiol 2004; 43:61.
  13. Krumholz HM, Chen YT, Vaccarino V, et al. Correlates and impact on outcomes of worsening renal function in patients > or =65 years of age with heart failure. Am J Cardiol 2000; 85:1110.
  14. Smith GL, Vaccarino V, Kosiborod M, et al. Worsening renal function: what is a clinically meaningful change in creatinine during hospitalization with heart failure? J Card Fail 2003; 9:13.
  15. Weinfeld MS, Chertow GM, Stevenson LW. Aggravated renal dysfunction during intensive therapy for advanced chronic heart failure. Am Heart J 1999; 138:285.
  16. Shamseddin MK, Parfrey PS. Mechanisms of the cardiorenal syndromes. Nat Rev Nephrol 2009; 5:641.
  17. Cowie MR, Komajda M, Murray-Thomas T, et al. Prevalence and impact of worsening renal function in patients hospitalized with decompensated heart failure: results of the prospective outcomes study in heart failure (POSH). Eur Heart J 2006; 27:1216.
  18. Damman K, Navis G, Voors AA, et al. Worsening renal function and prognosis in heart failure: systematic review and meta-analysis. J Card Fail 2007; 13:599.
  19. Gottlieb SS, Abraham W, Butler J, et al. The prognostic importance of different definitions of worsening renal function in congestive heart failure. J Card Fail 2002; 8:136.
  20. Logeart D, Tabet JY, Hittinger L, et al. Transient worsening of renal function during hospitalization for acute heart failure alters outcome. Int J Cardiol 2008; 127:228.
  21. Butler J, Forman DE, Abraham WT, et al. Relationship between heart failure treatment and development of worsening renal function among hospitalized patients. Am Heart J 2004; 147:331.
  22. Aronson D, Mittleman MA, Burger AJ. Elevated blood urea nitrogen level as a predictor of mortality in patients admitted for decompensated heart failure. Am J Med 2004; 116:466.
  23. Brisco MA, Coca SG, Chen J, et al. Blood urea nitrogen/creatinine ratio identifies a high-risk but potentially reversible form of renal dysfunction in patients with decompensated heart failure. Circ Heart Fail 2013; 6:233.
  24. Sarraf M, Masoumi A, Schrier RW. Cardiorenal syndrome in acute decompensated heart failure. Clin J Am Soc Nephrol 2009; 4:2013.
  25. Liang KV, Williams AW, Greene EL, Redfield MM. Acute decompensated heart failure and the cardiorenal syndrome. Crit Care Med 2008; 36:S75.
  26. Schrier RW, Abraham WT. Hormones and hemodynamics in heart failure. N Engl J Med 1999; 341:577.
  27. Kazory A. Emergence of blood urea nitrogen as a biomarker of neurohormonal activation in heart failure. Am J Cardiol 2010; 106:694.
  28. Lindenfeld J, Schrier RW. Blood urea nitrogen a marker for adverse effects of loop diuretics? J Am Coll Cardiol 2011; 58:383.
  29. Schrier RW. Blood urea nitrogen and serum creatinine: not married in heart failure. Circ Heart Fail 2008; 1:2.
  30. Testani JM, Cappola TP, Brensinger CM, et al. Interaction between loop diuretic-associated mortality and blood urea nitrogen concentration in chronic heart failure. J Am Coll Cardiol 2011; 58:375.
  31. Cadnapaphornchai MA, Gurevich AK, Weinberger HD, Schrier RW. Pathophysiology of sodium and water retention in heart failure. Cardiology 2001; 96:122.
  32. Stampfer M, Epstein SE, Beiser GD, Braunwald E. Hemodynamic effects of diuresis at rest and during intense upright exercise in patients with impaired cardiac function. Circulation 1968; 37:900.
  33. Nohria A, Hasselblad V, Stebbins A, et al. Cardiorenal interactions: insights from the ESCAPE trial. J Am Coll Cardiol 2008; 51:1268.
  34. Ljungman S, Laragh JH, Cody RJ. Role of the kidney in congestive heart failure. Relationship of cardiac index to kidney function. Drugs 1990; 39 Suppl 4:10.
  35. Wencker D. Acute cardio-renal syndrome: progression from congestive heart failure to congestive kidney failure. Curr Heart Fail Rep 2007; 4:134.
  36. Bradley SE, Bradley GP. THE EFFECT OF INCREASED INTRA-ABDOMINAL PRESSURE ON RENAL FUNCTION IN MAN. J Clin Invest 1947; 26:1010.
  37. BLAKE WD, WEGRIA R. Effect of increased renal venous pressure on renal function. Am J Physiol 1949; 157:1.
  38. Burnett JC Jr, Knox FG. Renal interstitial pressure and sodium excretion during renal vein constriction. Am J Physiol 1980; 238:F279.
  39. Dilley JR, Corradi A, Arendshorst WJ. Glomerular ultrafiltration dynamics during increased renal venous pressure. Am J Physiol 1983; 244:F650.
  40. Doty JM, Saggi BH, Sugerman HJ, et al. Effect of increased renal venous pressure on renal function. J Trauma 1999; 47:1000.
  41. Firth JD, Raine AE, Ledingham JG. Raised venous pressure: a direct cause of renal sodium retention in oedema? Lancet 1988; 1:1033.
  42. Abildgaard U, Amtorp O, Holstein-Rathlou NH, et al. Effect of renal venous pressure elevation on tubular sodium and water reabsorption in the dog kidney. Acta Physiol Scand 1988; 132:135.
  43. Mullens W, Abrahams Z, Francis GS, et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol 2009; 53:589.
  44. Damman K, van Deursen VM, Navis G, et al. Increased central venous pressure is associated with impaired renal function and mortality in a broad spectrum of patients with cardiovascular disease. J Am Coll Cardiol 2009; 53:582.
  45. Mullens W, Abrahams Z, Skouri HN, et al. Elevated intra-abdominal pressure in acute decompensated heart failure: a potential contributor to worsening renal function? J Am Coll Cardiol 2008; 51:300.
  46. Drazner MH, Rame JE, Stevenson LW, Dries DL. Prognostic importance of elevated jugular venous pressure and a third heart sound in patients with heart failure. N Engl J Med 2001; 345:574.
  47. Maeder MT, Holst DP, Kaye DM. Tricuspid regurgitation contributes to renal dysfunction in patients with heart failure. J Card Fail 2008; 14:824.
  48. Alpert JS. The effect of right ventricular dysfunction on left ventricular form and function. Chest 2001; 119:1632.
  49. Konstam, MA, Isner, J. The Right Ventricle, Konstam, MA, Isner, J (Eds), Kluwer Academic Publishers, 2009.
  50. Marcus JT, Vonk Noordegraaf A, Roeleveld RJ, et al. Impaired left ventricular filling due to right ventricular pressure overload in primary pulmonary hypertension: noninvasive monitoring using MRI. Chest 2001; 119:1761.
  51. Little WC, Badke FR, O'Rourke RA. Effect of right ventricular pressure on the end-diastolic left ventricular pressure-volume relationship before and after chronic right ventricular pressure overload in dogs without pericardia. Circ Res 1984; 54:719.
  52. Testani JM, Khera AV, St John Sutton MG, et al. Effect of right ventricular function and venous congestion on cardiorenal interactions during the treatment of decompensated heart failure. Am J Cardiol 2010; 105:511.