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CASE
Mrs. E.C. is a 81 year-old lady with CAD,
paroxysmal atrial fibrillation, chronic systolic
CHF (EF < 25%), severe pulmonary HTN (RV
pressure of 80 mmHg), progressive CKD
(currently at stage 4).
Admitted to hospital with worsening dyspnea
and edema, accompanied by a rise in serum
Cr from 2.2. to 3.0 mg/dL.
CASE
She is started on intravenous furosemide at
120 mg TID, and dobutamine drip.
CARDIORENAL SYNDROME
CARDIORENAL SYNDROME
Type 1: Acute heart failure
Type 2: Chronic HF
Type 3: AKI
Type 4: CKD
Type 5:
Systemic insult
AKI
CKD
CARDIORENAL SYNDROME
TYPE 1
Acute
Acute
CARDIORENAL SYNDROME
Over one million patients are admitted every
year for either de novo acute HF or acute
decompensation of chronic HF.
CARDIORENAL SYNDROME
Over one million patients are admitted every
year for either de novo acute HF or acute
decompensation of chronic HF.
These admission are frequently complicated
by AKI.
CARDIORENAL SYNDROME
Over one million patients are admitted every
year for either de novo acute HF or acute
decompensation of chronic HF.
These admission are frequently complicated
by AKI.
AKI seems to be more common in patients
with impaired LV function than those with
preserved LV function (>70% of patients with
cardiogenic shock).
CARDIORENAL SYNDROME
A rise as small as 0.3 mg/dL in serum Cr is an
independent risk factor for in-hospital and
1-year mortality in patients with acute HF,
STEMI, and after revascularization. (Goldberg A, etal,
Am Heart J 2005;150:330-7. Lassnigg A, et al, Crit Care Med 2008;36:1129-37)
OR
CRS 1
CRS 1
CRS 1
CRS 1
CRS 1
CRS 1
CRS 1
CRS 1
CVP
CI
SBP
PCWP
Changes in renal
parameters and
changes in IAP
Notice the initial rise in serum Cr and IAP with medical therapy
Mullens, W, et al. J Card. Fail. 2008;14:508-514
Decompensated CHF
Vasoconstriction and
venous congestion
CARDIORENAL SYNDROME
TYPE 2
Chronic
Chronic
CRS 2
Prevalence of renal dysfunction in chronic CHF
is approximately 25%.
CRS 2
Prevalence of renal dysfunction in chronic CHF
is approximately 25%.
Risk factors: Old age, Hypertension, Diabetes
mellitus, and Acute coronary syndrome.
CRS 2
Prevalence of renal dysfunction in chronic CHF
is approximately 25%.
Risk factors: Old age, Hypertension, Diabetes
mellitus, and Acute coronary syndrome.
No significant difference between HF with
reduced or preserved LV function.
CRS 2
CRS 2
CRS 2
CRS 2
CARDIORENAL SYNDROME
TYPE 3
Acute
Acute
Heart failure
Arrhythmia
ACS
CRS 3
AKI is present in 9% of all hospital admissions
and 35% of admissions to critical care unit.
CRS 3
AKI is present in 9% of all hospital admissions
and 35% of admissions to critical care unit.
CRS 3
CRS 3
CRS 3
CRS 3
CRS 3
Control hypertension
Correct electrolyte abnormalities
Control acidemia
Avoid fluid overload
Monitor patients closely for signs and
symptoms of cardiac complications
CARDIORENAL SYNDROME
TYPE 4
Chronic
Chronic
CRS Type 4
Up to 11% of US adult population has some
degree of CKD.
CRS Type 4
Up to 11% of US adult population has some
degree of CKD.
CRS Type 4
Up to 11% of US adult population has some
degree of CKD.
Patients with CKD have 10-20 fold higher risk of
cardiac death compared to age/gender matched
patients without CKD.
Two year mortality after MI in CKD 5 is 50%.
10 year mortality after MI in general population is
25%.
CRS 4
CRS 4
CRS 4
CRS 4
CARDIORENAL SYNDROME
TYPE 5
SYSTEMIC CONDITION
CRS 5
SUMMARY
Heart and kidney disease share similar
predisposing risk factors.
SUMMARY
The most important aspect of care is
prevention of injury, by managing risk factors,
establish an early diagnosis of organ injury,
and timely intervention.
A deeper understanding of pathophysiology of
cardiorenal syndrome, improves care and
outcome.
SUMMARY
A multi-disciplinary approach that includes the
nephrologist, cardiologist, and intensive care
specialist is preferred.
FUTURE
The role of biomarkers for kidney injury such
as Neutrophil gelatinase-associated lipocalin
(NGAL), Cystatin C, Kidney injury molecule 1
(KIM 1) in early diagnosis of AKI.
Role of biomarkers for early cardiac injury
such as Myeloperoxidase, Troponins, BNP, IL-6,
and IL-1.
FUTURE
Conducting cardiovascular studies in patients
with CKD to further clarify outcomes, optimal
therapeutic regimens, and goals.
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