Der Kardiologe

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Herz und Niere

Von der Risikostratifikation bis zu Wechselwirkungen der medikamentösen Therapien
CME Weiterbildung · Zertifizierte Fortbildung


Das kardiorenale Syndrom (CRS) findet sich im Krankheitsgut sowohl von Notaufnahmen, von Intensivstationen, insgesamt von Krankenhäusern, aber auch in Arztpraxen zunehmend häufiger. Ursache ist die demografische Entwicklung mit multimorbiden Patienten aufgrund kardiovaskulärer Risikokonstellationen. Oftmals bedingt eine Herzerkrankung auch eine Nierenerkrankung und umgekehrt. Das Management dieser Patienten ist schwierig, insbesondere da sich häufig widerstreitende Therapieziele finden. Für Nierenerkrankungen (CKD) gilt, dass diese kardiovaskuläre Risikofaktoren nicht nur leicht verstärken, sondern oftmals multiplizieren bis hin zu einer 100-fach höheren Erkrankungsrate an kardiovaskulären Erkrankungen (CVD). Weiterhin ist festzuhalten, dass eine CKD einen alleinigen kardiovaskulären Risikofaktor darstellt und derzeit in westlichen Industrieländern z. B. einen Diabetes mellitus als Risikofaktor für CVD deutlich überholt hat. Dies findet jedoch noch keinen Niederschlag im Bewusstsein von Patienten und Ärzten. Patienten mit CRS bedürfen modifizierter Therapien im Vergleich zu Patienten mit CVD ohne CKD. Die Therapieziele sind unterschiedlich, und Ergebnisse aus Studien mit Nierengesunden können nicht einfach auf diese Population extrapoliert werden.


Niereninsuffizienz Akutes Nierenversagen Kardiorenales Syndrom Kardiovaskuläre Erkrankungen Risikostratifikation 

Heart and kidney

From risk stratification to the interactions of pharmacotherapy


The cardiorenal syndrome (CRS) is seen in increasing numbers in emergency rooms, intensive care units, hospitals as a whole and outpatient departments. This is caused by the demographic shifts that lead to increasing numbers of elderly patients with multimorbidities. Often a heart disease is causing kidney failure and vice versa. The management of these patients is difficult due to the fact that often the goals of therapy are opposite. Patients with chronic kidney disease (CKD) have a 100-fold increased risk for the development of cardiovascular diseases (CVD). CKD alone is an important cardiovascular risk factor and has surpassed diabetes mellitus as a risk factor by far. However, awareness of this is low among doctors and patients. The treatment of patients with CRS is different from patients with CVD alone. The goals of therapy are different and the findings of studies in patients with CVD without CKD cannot simply be extended to these patients.


Renal impairment Acute kidney failure Cardiorenal syndrome Cardiovascular disease Risk stratification 


  1. 1.
    Coresh J, Selvin E, Stevens LA et al (2007) Prevalence of chronic kidney disease in the United States. JAMA 298:2038–2047CrossRefPubMedGoogle Scholar
  2. 2.
    Plantinga LC, Boulware LE, Coresh J et al (2008) Patient awareness of chronic kidney disease: trends and predictors. Arch Intern Med 168:2268–2275CrossRefPubMedGoogle Scholar
  3. 3.
    Palmer AJ, Valentine WJ, Chen R et al (2008) A health economic analysis of screening and optimal treatment of nephropathy in patients with type 2 diabetes and hypertension in the USA. Nephrol Dial Transplant 23:1216–1223CrossRefPubMedGoogle Scholar
  4. 4.
    Postma MJ, Boersma C, Gansevoort RT (2008) Pharmacoeconomics in nephrology: considerations on cost-effectiveness of screening for albuminuria. Nephrol Dial Transplant 23:1103–1106CrossRefPubMedGoogle Scholar
  5. 5.
    Moore SG, Shenoy PJ, Fanucchi L et al (2009) Cost-effectiveness of MRI compared to mammography for breast cancer screening in a high risk population. BMC Health Serv Res 9:9CrossRefPubMedGoogle Scholar
  6. 6.
    Ehlers L, Overvad K, Sorensen J et al (2009) Analysis of cost effectiveness of screening Danish men aged 65 for abdominal aortic aneurysm. BMJ 338:b2243CrossRefPubMedGoogle Scholar
  7. 7.
    Xie F, O’Reilly D, Ferrusi IL et al (2009) Illustrating economic evaluation of diagnostic technologies: comparing Helicobacter pylori screening strategies in prevention of gastric cancer in Canada. J Am Coll Radiol 6:317–323CrossRefPubMedGoogle Scholar
  8. 8.
    Ronco C, House AA, Haapio M (2008) Cardiorenal and renocardiac syndromes: the need for a comprehensive classification and consensus. Nat Clin Pract Nephrol 4:310–311CrossRefPubMedGoogle Scholar
  9. 9.
    Bellomo R, Ronco C, Kellum JA et al (2004) Acute renal failure – definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 8:R204–R212CrossRefPubMedGoogle Scholar
  10. 10.
    Mehta RL, Kellum JA, Shah SV et al (2007) Acute Kidney Injury Network: report of an initiative to improve outcomes in acute kidney injury. Crit Care 11:R31CrossRefPubMedGoogle Scholar
  11. 11.
    Foley RN, Parfrey PS, Sarnak MJ (1998) Epidemiology of cardiovascular disease in chronic renal disease. J Am Soc Nephrol 9:S16–S23PubMedGoogle Scholar
  12. 12.
    Yamamoto S, Kon V (2009) Mechanisms for increased cardiovascular disease in chronic kidney dysfunction. Curr Opin Nephrol Hypertens 18:181–188CrossRefPubMedGoogle Scholar
  13. 13.
    Weissberg PL, Bennett MR (1999) Atherosclerosis – an inflammatory disease. N Engl J Med 340:1928–1929CrossRefPubMedGoogle Scholar
  14. 14.
    Covic A, Kothawala P, Bernal M et al (2009) Systematic review of the evidence underlying the association between mineral metabolism disturbances and risk of all-cause mortality, cardiovascular mortality and cardiovascular events in chronic kidney disease. Nephrol Dial Transplant 24:1506–1523CrossRefPubMedGoogle Scholar
  15. 15.
    Schiele F (2009) Renal dysfunction and coronary disease: a high-risk combination. J Nephrol 22:39–45PubMedGoogle Scholar
  16. 16.
    Mathew S, Tustison KS, Sugatani T et al (2008) The mechanism of phosphorus as a cardiovascular risk factor in CKD. J Am Soc Nephrol 19:1092–1105CrossRefPubMedGoogle Scholar
  17. 17.
    Wen CP, Cheng TY, Tsai MK et al (2008) All-cause mortality attributable to chronic kidney disease: a prospective cohort study based on 462 293 adults in Taiwan. Lancet 371:2173–2182CrossRefPubMedGoogle Scholar
  18. 18.
    Campbell RC, Sui X, Filippatos G et al (2009) Association of chronic kidney disease with outcomes in chronic heart failure: a propensity-matched study. Nephrol Dial Transplant 24:186–193CrossRefPubMedGoogle Scholar
  19. 19.
    Charytan DM, Kuntz RE, Garshick M et al (2009) Location of acute coronary artery thromboses in patients with and without chronic kidney disease. Kidney Int 75:80–87CrossRefPubMedGoogle Scholar
  20. 20.
    Bax L, Algra A, Mali WP et al (2008) Renal function as a risk indicator for cardiovascular events in 3216 patients with manifest arterial disease. Atherosclerosis 200:184–190CrossRefPubMedGoogle Scholar
  21. 21.
    Yusuf S, Teo KK, Pogue J et al (2008) Telmisartan, ramipril, or both in patients at high risk for vascular events. N Engl J Med 358:1547–1559CrossRefPubMedGoogle Scholar
  22. 22.
    Phillips CO, Kashani A, Ko DK et al (2007) Adverse effects of combination angiotensin II receptor blockers plus angiotensin-converting enzyme inhibitors for left ventricular dysfunction: a quantitative review of data from randomized clinical trials. Arch Intern Med 167:1930–1936CrossRefPubMedGoogle Scholar
  23. 23.
    Wanner C, Krane V, Marz W et al (2005) Atorvastatin in patients with type 2 diabetes mellitus undergoing hemodialysis. N Engl J Med 353:238–248CrossRefPubMedGoogle Scholar
  24. 24.
    Strippoli GF, Navaneethan SD, Johnson DW et al (2008) Effects of statins in patients with chronic kidney disease: meta-analysis and meta-regression of randomised controlled trials. BMJ 336:645–651CrossRefPubMedGoogle Scholar
  25. 25.
    Chonchol M, Benderly M, Goldbourt U (2008) Beta-blockers for coronary heart disease in chronic kidney disease. Nephrol Dial Transplant 23:2274–2279CrossRefPubMedGoogle Scholar
  26. 26.
    Holman RR, Paul SK, Bethel MA et al (2008) 10-year follow-up of intensive glucose control in type 2 diabetes. N Engl J Med 359:1577–1589CrossRefPubMedGoogle Scholar
  27. 27.
    Duckworth W, Abraira C, Moritz T et al (2009) Glucose control and vascular complications in veterans with type 2 diabetes. N Engl J Med 360:129–139CrossRefPubMedGoogle Scholar
  28. 28.
    Mehrotra R, Kathuria P (2006) Place of peritoneal dialysis in the management of treatment-resistant congestive heart failure. Kidney Int Suppl S67–S71Google Scholar
  29. 29.
    Schrier RW (2007) Cardiorenal versus renocardiac syndrome: is there a difference? Nat Clin Pract Nephrol 3:637CrossRefPubMedGoogle Scholar
  30. 30.
    Kramer P, Schmidt-Lauber M, Langenheim N et al (1980) Reno-cardiac interactions in kidney failure (author’s transl). Klin Wochenschr 58:1043–1050CrossRefPubMedGoogle Scholar
  31. 31.
    Mishra J, Dent C, Tarabishi R et al (2005) Neutrophil gelatinase-associated lipocalin (NGAL) as a biomarker for acute renal injury after cardiac surgery. Lancet 365:1231–1238CrossRefPubMedGoogle Scholar
  32. 32.
    Cai L, Borowiec J, Xu S et al (2009) Assays of urine levels of HNL/NGAL in patients undergoing cardiac surgery and the impact of antibody configuration on their clinical performances. Clin Chim Acta 403:121–125CrossRefPubMedGoogle Scholar
  33. 33.
    Martin-Llahi M, Pepin MN, Guevara M et al (2008) Terlipressin and albumin vs albumin in patients with cirrhosis and hepatorenal syndrome: a randomized study. Gastroenterology 134:1352–1359CrossRefPubMedGoogle Scholar
  34. 34.
    Sanyal AJ, Boyer T, Garcia-Tsao G et al (2008) A randomized, prospective, double-blind, placebo-controlled trial of terlipressin for type 1 hepatorenal syndrome. Gastroenterology 134:1360–1368CrossRefPubMedGoogle Scholar
  35. 35.
    Gluud LL, Kjaer MS, Christensen E (2006) Terlipressin for hepatorenal syndrome. Cochrane Database Syst Rev CD005162Google Scholar
  36. 36.
    Lip GY, Beevers M, Beevers DG (1997) Does renal function improve after diagnosis of malignant phase hypertension? J Hypertens 15:1309–1315CrossRefPubMedGoogle Scholar
  37. 37.
    Ronco C, Chionh CY, Haapio M et al (2009) The cardiorenal syndrome. Blood Purif 27:114–126CrossRefPubMedGoogle Scholar
  38. 38.
    Parikh CR, Jani A, Mishra J et al (2006) Urine NGAL and IL-18 are predictive biomarkers for delayed graft function following kidney transplantation. Am J Transplant 6:1639–1645CrossRefPubMedGoogle Scholar
  39. 39.
    Frei U, Schober-Halstenberg H-J (2008) Nierenersatztherapie in Deutschland. Bericht über Dialysebehandlung und Nierentransplantation in Deutschland 2006I2007Google Scholar

Copyright information

© Springer Medizin Verlag 2009

Authors and Affiliations

  1. 1.Abteilung für Allgemeine Innere Medizin und NephrologieNotaufnahmezentrum, Robert-Bosch-KrankenhausStuttgartDeutschland

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