Cardio-renal syndromes: report from the consensus conference of the Acute Dialysis Quality Initiative

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Abstract

A consensus conference on cardio-renal syndromes (CRS) was held in Venice Italy, in September 2008 under the auspices of the Acute Dialysis Quality Initiative (ADQI). The following topics were matter of discussion after a systematic literature review and the appraisal of the best available evidence: definition/classification system; epidemiology; diagnostic criteria and biomarkers; prevention/protection strategies; management and therapy. The umbrella term CRS was used to identify a disorder of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction in the other organ. Different syndromes were identified and classified into five subtypes. Acute CRS (type 1): acute worsening of heart function (AHF–ACS) leading to kidney injury and/or dysfunction. Chronic cardio-renal syndrome (type 2): chronic abnormalities in heart function (CHF-CHD) leading to kidney injury and/or dysfunction. Acute reno-cardiac syndrome (type 3): acute worsening of kidney function (AKI) leading to heart injury and/or dysfunction. Chronic reno-cardiac syndrome (type 4): chronic kidney disease leading to heart injury, disease, and/or dysfunction. Secondary CRS (type 5): systemic conditions leading to simultaneous injury and/or dysfunction of heart and kidney. Consensus statements concerning epidemiology, diagnosis, prevention, and management strategies are discussed in the paper for each of the syndromes.

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Cardiorenal syndrome.

Claudio Ronco, Mikko Haapio, Andrew House … (2008)

The term cardiorenal syndrome (CRS) increasingly has been used without a consistent or well-accepted definition. To include the vast array of interrelated derangements, and to stress the bidirectional nature of heart-kidney interactions, we present a new classification of the CRS with 5 subtypes that reflect the pathophysiology, the time-frame, and the nature of concomitant cardiac and renal dysfunction. CRS can be generally defined as a pathophysiologic disorder of the heart and kidneys whereby acute or chronic dysfunction of 1 organ may induce acute or chronic dysfunction of the other. Type 1 CRS reflects an abrupt worsening of cardiac function (e.g., acute cardiogenic shock or decompensated congestive heart failure) leading to acute kidney injury. Type 2 CRS comprises chronic abnormalities in cardiac function (e.g., chronic congestive heart failure) causing progressive chronic kidney disease. Type 3 CRS consists of an abrupt worsening of renal function (e.g., acute kidney ischemia or glomerulonephritis) causing acute cardiac dysfunction (e.g., heart failure, arrhythmia, ischemia). Type 4 CRS describes a state of chronic kidney disease (e.g., chronic glomerular disease) contributing to decreased cardiac function, cardiac hypertrophy, and/or increased risk of adverse cardiovascular events. Type 5 CRS reflects a systemic condition (e.g., sepsis) causing both cardiac and renal dysfunction. Biomarkers can contribute to an early diagnosis of CRS and to a timely therapeutic intervention. The use of this classification can help physicians characterize groups of patients, provides the rationale for specific management strategies, and allows the design of future clinical trials with more accurate selection and stratification of the population under investigation.

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Chronic kidney disease and mortality risk: a systematic review.

Marcello Tonelli, Natasha Wiebe, Bruce Culleton … (2006)

Current guidelines identify people with chronic kidney disease (CKD) as being at high risk for cardiovascular and all-cause mortality. Because as many as 19 million Americans may have CKD, a comprehensive summary of this risk would be potentially useful for planning public health policy. A systematic review of the association between non-dialysis-dependent CKD and the risk for all-cause and cardiovascular mortality was conducted. Patient- and study-related characteristics that influenced the magnitude of these associations also were investigated. MEDLINE and EMBASE databases were searched, and reference lists through December 2004 were consulted. Authors of 10 primary studies provided additional data. Cohort studies or cohort analyses of randomized, controlled trials that compared mortality between those with and without chronically reduced kidney function were included. Studies were excluded from review when participants were followed for < 1 yr or had ESRD. Two reviewers independently extracted data on study setting, quality, participant and renal function characteristics, and outcomes. Thirty-nine studies that followed a total of 1,371,990 participants were reviewed. The unadjusted relative risk for mortality in participants with reduced kidney function compared with those without ranged from 0.94 to 5.0 and was significantly more than 1.0 in 93% of cohorts. Among the 16 studies that provided suitable data, the absolute risk for death increased exponentially with decreasing renal function. Fourteen cohorts described the risk for mortality from reduced kidney function, after adjustment for other established risk factors. Although adjusted relative hazards were consistently lower than unadjusted relative risks (median reduction 17%), they remained significantly more than 1.0 in 71% of cohorts. This review supports current guidelines that identify individuals with CKD as being at high risk for cardiovascular mortality. Determining which interventions best offset this risk remains a health priority.

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Importance of venous congestion for worsening of renal function in advanced decompensated heart failure.

Wilfried Mullens, Zuheir Abrahams, Gary Francis … (2009)

To determine whether venous congestion, rather than impairment of cardiac output, is primarily associated with the development of worsening renal function (WRF) in patients with advanced decompensated heart failure (ADHF). Reduced cardiac output is traditionally believed to be the main determinant of WRF in patients with ADHF. A total of 145 consecutive patients admitted with ADHF treated with intensive medical therapy guided by pulmonary artery catheter were studied. We defined WRF as an increase of serum creatinine >/=0.3 mg/dl during hospitalization. In the study cohort (age 57 +/- 14 years, cardiac index 1.9 +/- 0.6 l/min/m(2), left ventricular ejection fraction 20 +/- 8%, serum creatinine 1.7 +/- 0.9 mg/dl), 58 patients (40%) developed WRF. Patients who developed WRF had a greater central venous pressure (CVP) on admission (18 +/- 7 mm Hg vs. 12 +/- 6 mm Hg, p < 0.001) and after intensive medical therapy (11 +/- 8 mm Hg vs. 8 +/- 5 mm Hg, p = 0.04). The development of WRF occurred less frequently in patients who achieved a CVP <8 mm Hg (p = 0.01). Furthermore, the ability of CVP to stratify risk for development of WRF was apparent across the spectrum of systemic blood pressure, pulmonary capillary wedge pressure, cardiac index, and estimated glomerular filtration rates. Venous congestion is the most important hemodynamic factor driving WRF in decompensated patients with advanced heart failure.

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Author and article information

Journal

Journal ID (nlm-ta): Eur Heart J

Journal ID (publisher-id): eurheartj

Journal ID (hwp): ehj

Title: European Heart Journal

Publisher: Oxford University Press

ISSN (Print): 0195-668X

ISSN (Electronic): 1522-9645

Publication date (Print): March 2010

Publication date (Electronic): 25 December 2009

Publication date PMC-release: 25 December 2009

Volume: 31

Issue: 6

Pages: 703-711

Affiliations

[1 ]Department of Nephrology, simpleSan Bortolo Hospital , Viale Rodolfi 37, Vicenza 36100, Italy

[2 ]IRRIV, International Renal Research Institute of Vicenza, simpleVicenza , Italy

[3 ]Division of Cardiology, Department of Medicine, Nutrition and Preventive Medicine, simpleWilliam Beaumont Hospital , Royal Oak, MI, USA

[4 ]Department of Cardiology, simpleApplied Cachexia Research , Charité, Campus Virchow-Klinikum, Berlin, Germany

[5 ]simpleCentre for Clinical and Basic Research, IRCCS San Raffaele , Rome, Italy

[6 ]Department of Cardiology, simpleVA Medical Centre , Minneapolis, MN, USA

[7 ]Department of Cardiology, simpleSt Spirito Hospital , Rome, Italy

[8 ]Division of Critical Care Medicine, simpleUniversity of Alberta Hospital , Edmonton, Canada

[9 ]Department of Intensive Care, simpleAustin Hospital , Melbourne, Australia

[10 ]Department of Nephrology, simpleUniversity of Colorado Health Sciences Center , Denver, CO, USA

[11 ]Department of Cardiology, simpleUniversity of Padova , Padova, Italy

[12 ]UCL Center for Nephrology, simpleRoyal Free and University College Medical School , London, UK

[13 ]Division of Nephrology, simpleHelsinki University Central Hospital , Helsinki, Finland

[14 ]Trial Coordination Center, Department of Cardiology and Epidemiology, simpleUniversity Medical Center Groningen , Hanzeplein, The Netherlands

[15 ]Division of Nephrology, simpleLondon Health Sciences Centre, University Hospital , London, Ont, Canada

[16 ]Department of Surgery, simpleThe George Washington University , Washington, DC, USA

[17 ]Department of Medicine and Cardiology, simpleSan Diego VA Medical Center and University of California , San Diego, CA, USA

[18 ]Department of Cardiology, simpleMayo Clinic , Rochester, MN, USA

[19 ]Department of Nuclear Medicine, simpleSan Bortolo Hospital , Vicenza, Italy

[20 ]Department of Anesthesiology and Critical Care Medicine, simpleHôpital Lariboisière. U 942 Inserm; University Paris 7 , Paris Diderot, France

[21 ]Department of Internal Medicine, simpleUniversity of Siena, Le Scotte Hospital , Siena, Italy

[22 ]Department of Anesthesiology, simpleDuke University Medical Center , Durham, NC, USA

[23 ]Department of Critical Care, simpleUniversity of Maryland , College Park, MD, USA

[24 ]Division of Nephrology, simpleMediciti Hospitals , Hyderabad, India

[25 ]Department of Internal Medicine, simpleSan Bortolo Hospital , Vicenza, Italy

[26 ]Department of Intensive Care, simpleSan Bortolo Hospital , Vicenza, Italy

[27 ]Cardiac Department, Faculty of Public Health, simpleMedical University, Military Hospital , Wroclaw, Poland

Author notes

[* ]Corresponding author. Email: cronco@ 123456goldnet.it

Article

Publisher ID: ehp507

DOI: 10.1093/eurheartj/ehp507

PMC ID: 2838681

PubMed ID: 20037146

SO-VID: 17ab2207-af66-4f6c-819e-daf2186bb380

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The online version of this article has been published under an open access model. Users are entitled to use, reproduce, disseminate, or display the open access version of this article for non-commercial purposes provided that the original authorship is properly and fully attributed; the Journal, Learned Society and Oxford University Press are attributed as the original place of publication with correct citation details given; if an article is subsequently reproduced or disseminated not in its entirety but only in part or as a derivative work this must be clearly indicated. For commercial re-use, please contact journals.permissions@oxfordjournals.org

History

Date received : 15 June 2009

Date revision received : 7 August 2009

Date accepted : 12 October 2009

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Cardio-renal syndromes: report from the consensus conference of the Acute Dialysis Quality Initiative

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Karger: Nephrology

Most cited references 119

Cardiorenal syndrome.

Chronic kidney disease and mortality risk: a systematic review.

Importance of venous congestion for worsening of renal function in advanced decompensated heart failure.

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Cited by 247

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