Abstract
Worsening renal function during the treatment of acute decompensated heart failure, so-called acute cardio-renal syndrome, is very common and complicates the treatment course. The underlying pathophysiology of worsening renal function (WRF) involves variable contributions of renal hemodynamics, neurohormonal activity, and oxidative stress. Historically, WRF has been associated with adverse outcomes. However, emerging data support therapeutic strategies that permit WRF while effectively treating congestion as they are associated with improved outcomes.
Similar content being viewed by others
References
Papers of particular interest, published recently, have been highlighted as: • Of importance
Bock JS, Gottlieb SS. Cardiorenal syndrome: new perspectives. Circulation. 2010;121(23):2592–600.
Shchekochikhin D, Schrier RW, Lindenfeld J. Cardiorenal syndrome: pathophysiology and treatment. Curr Cardiol Rep. 2013;15(7):380.
Damman K, Navis G, Voors AA, Asselbergs FW, Smilde TD, Cleland JG, et al. Worsening renal function and prognosis in heart failure: systematic review and meta-analysis. J Card Fail. 2007;13(8):599–608.
Gottlieb SS, Abraham W, Butler J, Forman DE, Loh E, Massie BM, et al. The prognostic importance of different definitions of worsening renal function in congestive heart failure. J Card Fail. 2002;8(3):136–41.
Mentz RJ, O’Connor CM. Cardiorenal syndrome clinical trial end points. Heart Fail Clin. 2011;7(4):519–28. An original and critical view on clinical trial end points in the domain of cardiorenal interactions.
Ronco C, Di Lullo L. Cardiorenal syndrome. Heart Fail Clin. 2014;10(2):251–80.
Boron WFBE. Medical physiology: a cellular and molecular approach. Philadelphia: Saunders Elsevier; 2009.
Damman K, Masson S, Hillege HL, Voors AA, van Veldhuisen DJ, Rossignol P, et al. Tubular damage and worsening renal function in chronic heart failure. JACC Heart Fail. 2013;1(5):417–24.
Dupont M, Shrestha K, Singh D, Awad A, Kovach C, Scarcipino M, et al. Lack of significant renal tubular injury despite acute kidney injury in acute decompensated heart failure. Eur J Heart Fail. 2012;14(6):597–604.
Testani JM, Coca SG, Shannon RP, Kimmel SE, Cappola TP. Influence of renal dysfunction phenotype on mortality in the setting of cardiac dysfunction: analysis of three randomized controlled trials. Eur J Heart Fail. 2011;13(11):1224–30. This article emphasizes that a negative outcome in HF appears to be contingent not simply on the presence of a reduced GFR, but probably on the underlying cause of WRF.
Wald R, Jaber BL, Price LL, Upadhyay A, Madias NE. Impact of hospital-associated hyponatremia on selected outcomes. Arch Intern Med. 2010;170(3):294–302.
Lin HJ, Chao CL, Chien KL, Ho YL, Lee CM, Lin YH, et al. Elevated blood urea nitrogen-to-creatinine ratio increased the risk of hospitalization and all-cause death in patients with chronic heart failure. Clin Res Cardiol Off J Ger Card Soc. 2009;98(8):487–92.
Ezekowitz J, McAlister FA, Humphries KH, Norris CM, Tonelli M, Ghali WA, 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(8):1587–92.
Heywood JT, Fonarow GC, Costanzo MR, Mathur VS, Wigneswaran JR, Wynne J, 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(6):422–30.
Hebert K, Dias A, Delgado MC, Franco E, Tamariz L, Steen D, et al. Epidemiology and survival of the five stages of chronic kidney disease in a systolic heart failure population. Eur J Heart Fail. 2010;12(8):861–5.
Cruz DN, Bagshaw SM. Heart-kidney interaction: epidemiology of cardiorenal syndromes. Int J Nephrol. 2010;2011:351291.
Hillege HL, Girbes AR, de Kam PJ, Boomsma F, de Zeeuw D, Charlesworth A, et al. Renal function, neurohormonal activation, and survival in patients with chronic heart failure. Circulation. 2000;102(2):203–10.
Forman DE, Butler J, Wang Y, Abraham WT, O’Connor CM, Gottlieb SS, et al. Incidence, predictors at admission, and impact of worsening renal function among patients hospitalized with heart failure. J Am Coll Cardiol. 2004;43(1):61–7.
Nohria A, Hasselblad V, Stebbins A, Pauly DF, Fonarow GC, Shah M, et al. Cardiorenal interactions: insights from the ESCAPE trial. J Am Coll Cardiol. 2008;51(13):1268–74.
Weinfeld MS, Chertow GM, Stevenson LW. Aggravated renal dysfunction during intensive therapy for advanced chronic heart failure. Am Heart J. 1999;138(2 Pt 1):285–90.
Krumholz HM, Chen YT, Vaccarino V, Wang Y, Radford MJ, Bradford WD, 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(9):1110–3.
Metra M, Davison B, Bettari L, Sun H, Edwards C, Lazzarini V, et al. Is worsening renal function an ominous prognostic sign in patients with acute heart failure? The role of congestion and its interaction with renal function. Circ Heart Fail. 2012;5(1):54–62. This article states WRF is not an independent determent of outcome in patients with ADHF but the association with congestion determines the negative of neutral prognostic value.
Testani JM, Chen J, McCauley BD, Kimmel SE, Shannon RP. Potential effects of aggressive decongestion during the treatment of decompensated heart failure on renal function and survival. Circulation. 2010;122(3):265–72.
Testani JM, McCauley BD, Chen J, Coca SG, Cappola TP, Kimmel SE. Clinical characteristics and outcomes of patients with improvement in renal function during the treatment of decompensated heart failure. J Card Fail. 2011;17(12):993–1000.
Dupont M, Mullens W, Finucan M, Taylor DO, Starling RC, Tang WH. Determinants of dynamic changes in serum creatinine in acute decompensated heart failure: the importance of blood pressure reduction during treatment. Eur J Heart Fail. 2013;15(4):433–40. The importance of simple hemodynamic parameters, blood pressure changes during treatment, in the pathophysiology of WRF was elegantly investigated in this observational study.
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 4:10–21. discussion 2–4.
Rusinaru D, Buiciuc O, Houpe D, Tribouilloy C. Renal function and long-term survival after hospital discharge in heart failure with preserved ejection fraction. Int J Cardiol. 2011;147(2):278–82.
Mullens W, Abrahams Z, Francis GS, Sokos G, Taylor DO, Starling RC, et al. Importance of venous congestion for worsening of renal function in advanced decompensated heart failure. J Am Coll Cardiol. 2009;53(7):589–96.
Mullens W, Abrahams Z, Skouri HN, Francis GS, Taylor DO, Starling RC, et al. Elevated intra-abdominal pressure in acute decompensated heart failure: a potential contributor to worsening renal function? J Am Coll Cardiol. 2008;51(3):300–6.
Triposkiadis FK, Butler J, Karayannis G, Starling RC, Filippatos G, Wolski K, et al. Efficacy and safety of high dose versus low dose furosemide with or without dopamine infusion: the Dopamine in Acute Decompensated Heart Failure II (DAD-HF II) trial. Int J Cardiol. 2014;172(1):115–21.
Giamouzis G, Butler J, Starling RC, Karayannis G, Nastas J, Parisis C, et al. Impact of dopamine infusion on renal function in hospitalized heart failure patients: results of the Dopamine in Acute Decompensated Heart Failure (DAD-HF) Trial. J Card Fail. 2010;16(12):922–30.
Yancy CW, Lopatin M, Stevenson LW, De Marco T, Fonarow GC. Clinical presentation, management, and in-hospital outcomes of patients admitted with acute decompensated heart failure with preserved systolic function: a report from the Acute Decompensated Heart Failure National Registry (ADHERE) Database. J Am Coll Cardiol. 2006;47(1):76–84.
Zile MR, Bennett TD, St John Sutton M, Cho YK, Adamson PB, Aaron MF, et al. Transition from chronic compensated to acute decompensated heart failure: pathophysiological insights obtained from continuous monitoring of intracardiac pressures. Circulation. 2008;118(14):1433–41.
Adams Jr KF, Fonarow GC, Emerman CL, LeJemtel TH, Costanzo MR, Abraham WT, 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(2):209–16.
Fiksen-Olsen MJ, Romero JC. Renal effects of prostaglandin inhibition during increases in renal venous pressure. Am J Physiol. 1991;260(4 Pt 2):F525–9.
Fiksen-Olsen MJ, Strick DM, Hawley H, Romero JC. Renal effects of angiotensin II inhibition during increases in renal venous pressure. Hypertension. 1992;19(2 Suppl):II137–41.
Maxwell MH, Breed ES, Schwartz IL. Renal venous pressure in chronic congestive heart failure. J Clin Invest. 1950;29:342–8.
Damman K, van Deursen VM, Navis G, Voors AA, van Veldhuisen DJ, Hillege HL. 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(7):582–8.
Winton FR. The influence of venous pressure on the isolated mammalian kidney. J Physiol. 1931;72(1):49–61.
Burnett Jr JC, Knox FG. Renal interstitial pressure and sodium excretion during renal vein constriction. Am J Physiol. 1980;238(4):F279–82.
Wathen RL, Selkurt EE. Intrarenal regulatory factors of salt excretion during renal venous pressure elevation. Am J Physiol. 1969;216(6):1517–24.
Kastner PR, Hall JE, Guyton AC. Renal hemodynamic responses to increased renal venous pressure: role of angiotensin II. Am J Physiol. 1982;243(3):F260–4.
Tang WH, Mullens W. Cardiorenal syndrome in decompensated heart failure. Heart. 2010;96(4):255–60.
Verbrugge FH, Grieten L, Mullens W. New insights into combinational drug therapy to manage congestion in heart failure. Curr Heart Fail Rep. 2014;11(1):1–9.
Felker GM, Lee KL, Bull DA, Redfield MM, Stevenson LW, Goldsmith SR, et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med. 2011;364(9):797–805.
Costanzo MR, Guglin ME, Saltzberg MT, Jessup ML, Bart BA, Teerlink JR, et al. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol. 2007;49(6):675–83.
Voors AA, Davison BA, Felker GM, Ponikowski P, Unemori E, Cotter G, et al. Early drop in systolic blood pressure and worsening renal function in acute heart failure: renal results of Pre-RELAX-AHF. Eur J Heart Fail. 2011;13(9):961–7.
Bradley SE, Bradley GP. The effect of increased intra-abdominal pressure on renal function in man. J Clin Invest. 1947;26:1010–22.
Doty JM, Saggi BH, Sugerman HJ. Effect of intravenous renal venous pressure on renal function. J Trauma. 1999;47:1000–3.
Malbrain MD, Deeren D, De Potter TJ. Intra-abdominal hypertension in the critically ill: it is time to pay attention. Curr Opin Crit Care. 2005;11:156–71.
Mullens W, Abrahams Z, Francis GS, Taylor DO, Starling RC, Tang WH. Prompt reduction in intra-abdominal pressure following large-volume mechanical fluid removal improves renal insufficiency in refractory decompensated heart failure. J Card Fail. 2008;14(6):508–14.
Szymanski MK, Damman K, van Veldhuisen DJ, van Gilst WH, Hillege HL, de Boer RA. Prognostic value of renin and prorenin in heart failure patients with decreased kidney function. Am Heart J. 2011;162(3):487–93.
Poletti R, Vergaro G, Zyw L, Prontera C, Passino C, Emdin M. Prognostic value of plasma renin activity in heart failure patients with chronic kidney disease. Int J Cardiol. 2013;167(3):711–5.
Colombo PC, Onat D, Harxhi A, Demmer RT, Hayashi Y, Jelic S, et al. Peripheral venous congestion causes inflammation, neurohormonal, and endothelial cell activation. Eur Heart J. 2014;35(7):448–54.
Ruiz-Ortega M, Ruperez M, Lorenzo O, Esteban V, Blanco J, Mezzano S, et al. Angiotensin II regulates the synthesis of proinflammatory cytokines and chemokines in the kidney. Kidney Int Suppl. 2002;82:S12–22.
Remuzzi G, Perico N, Macia M, Ruggenenti P. The role of renin-angiotensin-aldosterone system in the progression of chronic kidney disease. Kidney Int Suppl. 2005;99:S57–65.
Clark H, Krum H, Hopper I. Worsening renal function during renin-angiotensin-aldosterone system inhibitor initiation and long-term outcomes in patients with left ventricular systolic dysfunction. Eur J Heart Fail. 2014;16(1):41–8.
Ewen S, Ukena C, Linz D, Schmieder RE, Bohm M, Mahfoud F. The sympathetic nervous system in chronic kidney disease. Curr Hypertens Rep. 2013;15(4):370–6.
Gluck Z, Reubi FC. Acute changes in renal function induced by bisoprolol, a new cardioselective beta-blocking agent. Eur J Clin Pharmacol. 1986;31(1):107–11.
Castagno D, Jhund PS, McMurray JJ, Lewsey JD, Erdmann E, Zannad F, et al. Improved survival with bisoprolol in patients with heart failure and renal impairment: an analysis of the cardiac insufficiency bisoprolol study II (CIBIS-II) trial. Eur J Heart Fail. 2010;12(6):607–16.
Ghali JK, Wikstrand J, Van Veldhuisen DJ, Fagerberg B, Goldstein S, Hjalmarson A, et al. The influence of renal function on clinical outcome and response to beta-blockade in systolic heart failure: insights from Metoprolol CR/XL Randomized Intervention Trial in Chronic HF (MERIT-HF). J Card Fail. 2009;15(4):310–8.
Bohm M, Ewen S, Kindermann I, Linz D, Ukena C, Mahfoud F. Renal denervation and heart failure. Eur J Heart Fail. 2014;16(6):608–13.
Schlaich MP, Sobotka PA, Krum H, Lambert E, Esler MD. Renal sympathetic-nerve ablation for uncontrolled hypertension. N Engl J Med. 2009;361(9):932–4.
Griendling KK, Minieri CA, Ollerenshaw JD, Alexander RW. Angiotensin II stimulates NADH and NADPH oxidase activity in cultured vascular smooth muscle cells. Circ Res. 1994;74(6):1141–8.
Heymes C, Bendall JK, Ratajczak P, Cave AC, Samuel JL, Hasenfuss G, et al. Increased myocardial NADPH oxidase activity in human heart failure. J Am Coll Cardiol. 2003;41(12):2164–71.
Vaziri ND, Dicus M, Ho ND, Boroujerdi-Rad L, Sindhu RK. Oxidative stress and dysregulation of superoxide dismutase and NADPH oxidase in renal insufficiency. Kidney Int. 2003;63(1):179–85.
Hornig B, Landmesser U, Kohler C, Ahlersmann D, Spiekermann S, Christoph A, et al. Comparative effect of ace inhibition and angiotensin II type 1 receptor antagonism on bioavailability of nitric oxide in patients with coronary artery disease: role of superoxide dismutase. Circulation. 2001;103(6):799–805.
Jie KE, Verhaar MC, Cramer MJ, van der Putten K, Gaillard CA, Doevendans PA, et al. Erythropoietin and the cardiorenal syndrome: cellular mechanisms on the cardiorenal connectors. Am J Physiol Ren Physiol. 2006;291(5):F932–44.
Pergola PE, Raskin P, Toto RD, Meyer CJ, Huff JW, Grossman EB, et al. Bardoxolone methyl and kidney function in CKD with type 2 diabetes. N Engl J Med. 2011;365(4):327–36.
de Zeeuw D, Akizawa T, Audhya P, Bakris GL, Chin M, Christ-Schmidt H, et al. Bardoxolone methyl in type 2 diabetes and stage 4 chronic kidney disease. N Engl J Med. 2013;369(26):2492–503.
Konstam MA, Gheorghiade M, Burnett Jr JC, Grinfeld L, Maggioni AP, Swedberg K, et al. Effects of oral tolvaptan in patients hospitalized for worsening heart failure: the EVEREST Outcome Trial. JAMA J Am Med Assoc. 2007;297(12):1319–31.
O’Connor CM, Starling RC, Hernandez AF, Armstrong PW, Dickstein K, Hasselblad V, et al. Effect of nesiritide in patients with acute decompensated heart failure. N Engl J Med. 2011;365(1):32–43.
Chen HH, Anstrom KJ, Givertz MM, Stevenson LW, Semigran MJ, Goldsmith SR, et al. Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: the ROSE acute heart failure randomized trial. JAMA J Am Med Assoc. 2013;310(23):2533–43.
Massie BM, O’Connor CM, Metra M, Ponikowski P, Teerlink JR, Cotter G, et al. Rolofylline, an adenosine A1-receptor antagonist, in acute heart failure. N Engl J Med. 2010;363(15):1419–28.
Bart BA, Goldsmith SR, Lee KL, Givertz MM, O’Connor CM, Bull DA, et al. Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med. 2012;367(24):2296–304.
Teerlink JR, Cotter G, Davison BA, Felker GM, Filippatos G, Greenberg BH, et al. Serelaxin, recombinant human relaxin-2, for treatment of acute heart failure (RELAX-AHF): a randomised, placebo-controlled trial. Lancet. 2013;381(9860):29–39.
Metra M, Cotter G, Davison BA, Felker GM, Filippatos G, Greenberg BH, et al. Effect of serelaxin on cardiac, renal, and hepatic biomarkers in the Relaxin in Acute Heart Failure (RELAX-AHF) development program: correlation with outcomes. J Am Coll Cardiol. 2013;61(2):196–206.
Heart Failure Society of A, Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, et al. HFSA 2010 comprehensive heart failure practice guideline. J Card Fail. 2010;16(6):e1–194.
Smith GL, Lichtman JH, Bracken MB, Shlipak MG, Phillips CO, DiCapua P, et al. Renal impairment and outcomes in heart failure: systematic review and meta-analysis. J Am Coll Cardiol. 2006;47(10):1987–96.
Compliance with Ethics Guidelines
Conflict of Interest
Petra Nijst and Wilfried Mullens declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Nijst, P., Mullens, W. The Acute Cardiorenal Syndrome: Burden and Mechanisms of Disease. Curr Heart Fail Rep 11, 453–462 (2014). https://doi.org/10.1007/s11897-014-0218-4
Published:
Issue Date:
DOI: https://doi.org/10.1007/s11897-014-0218-4