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Anemia, chronic renal disease and congestive heart failure—the cardio renal anemia syndrome: the need for cooperation between cardiologists and nephrologists

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Abstract

Many patients with congestive heart failure (CHF) fail to respond to maximal CHF therapy and progress to end stage CHF with many hospitalizations, poor quality of life (QoL), progressive chronic kidney disease (CKD) which can lead to end stage kidney disease (ESKD), or die of cardiovascular complications within a short time. One factor that has generally been ignored in many of these people is the fact that they are often anemic. The anemia in CHF is due mainly to the frequently-associated CKD but also to the inhibitory effects of cytokines on erythropoietin production and on bone marrow activity, as well as to their interference with iron absorption from the gut and their inhibiting effect on the release of iron from iron stores. Anemia itself may further worsen cardiac and renal function and make the patients resistant to standard CHF therapy. Indeed anemia in CHF has been associated with increased severity of CHF, increased hospitalization, worse cardiac function and functional class, the need for higher doses of diuretics, progressive worsening of renal function and reduced QoL. In both controlled and uncontrolled studies of CHF, the correction of the anemia with erythropoietin (EPO) and oral or intravenous (IV) iron has been associated with improvement in many cardiac and renal parameters and an increased QoL. EPO itself may also play a direct role in improving the heart unrelated to the improvement of the anemia—by reducing apoptosis of cardiac and endothelial cells, increasing the number of endothelial progenitor cells, and improving endothelial cell function and neovascularization of the heart. Anemia may also play a role in the worsening of acute myocardial infarction and chronic coronary heart disease (CHD) and in the cardiovascular complications of renal transplantation. Anemia, CHF and CKD interact as a vicious circle so as to cause or worsen each other- the so-called cardio renal anemia syndrome. Only adequate treatment of all three conditions can prevent the CHF and CKD from progressing.

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Abbreviations

ARB:

angiotensin receptor blocker

ACEI:

angiotensin converting enzyme inhibitor

ANP:

atrial natriuretic peptide

BNP:

brain natriuretic peptide

CCr:

creatinine clearance

CHF:

congestive heart failure

CKD:

chronic kidney disease

ESKD:

end stage kidney disease

LVEF:

left ventricular ejection fraction

LVH:

left ventricular hypertrophy

MVO2 :

oxygen utilization during peak exercise

NYHA:

New York Heart Association functional class

PCI:

percutaneous coronary intervention

TNFα:

tumor necrosis factor alpha

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Authors and Affiliations

  1. Department of Nephrology, Tel Aviv Medical Center, Weizman 6, 64239, Tel Aviv, Israel

    Donald S. Silverberg, Adrian Iaina, Shoshana Steinbruch, Y. Wollman & Doron Schwartz

  2. Department of Cardiology and Heart Failure Clinic, Tel Aviv Medical Center, Weizman 6, 64239, Tel Aviv, Israel

    Dov Wexler

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  1. Donald S. Silverberg
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Correspondence to Donald S. Silverberg.

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Silverberg, D.S., Wexler, D., Iaina, A. et al. Anemia, chronic renal disease and congestive heart failure—the cardio renal anemia syndrome: the need for cooperation between cardiologists and nephrologists. Int Urol Nephrol 38, 295–310 (2006). https://doi.org/10.1007/s11255-006-0064-8

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