STATE-OF-THE-ART PAPER
Cardiorenal Syndrome
Claudio Ronco, MD*,*,
Mikko Haapio, MD ,
Andrew A. House, MSc, MD ,
Nagesh Anavekar, MD and
Rinaldo Bellomo, MD¶
* Department of Nephrology, St. Bortolo Hospital, Vicenza, Italy
Division of Nephrology, Helsinki University Central Hospital, Helsinki, Finland
Division of Nephrology, London Health Sciences Centre, London, Ontario, Canada
Department of Cardiology, Northern Hospital, Melbourne, Australia
¶ Department of Intensive Care, Austin Hospital, Melbourne, Australia
Manuscript received June 12, 2008;
revised manuscript received July 14, 2008,
accepted July 28, 2008.
* Reprint requests and correspondence: Dr. Claudio Ronco, Department of Nephrology, St. Bortolo Hospital, Viale Rodolfi 37, 36100 Vicenza, Italy (Email: cronco{at}goldnet.it).
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.
Key Words: chronic kidney disease • heart failure • cardiorenal syndrome • renocardiac syndrome • heart-kidney interaction • biomarkers • cardiovascular risk
|
Abbreviations and Acronyms
| | ACE = angiotensin-converting enzyme | | AKI = acute kidney injury | | ARB = angiotensin receptor blocker | | BNP = B-type natriuretic peptide | | CKD = chronic kidney disease | | CRS = cardiorenal syndrome | | GFR = glomerular filtration rate | | HF = heart failure | | ICU = intensive care unit | | IL = interleukin | | LV = left ventricular | | NGAL = neutrophil gelatinase-associated lipocalin | | TNF = tumor necrosis factor |
|
Related Article
-
Inside This Issue of JACC
J. Am. Coll. Cardiol. 2008 52: A40.
[Full Text]
[PDF]
This article has been cited by other articles:
|
|
|
|
 
T. M. H. Ng, K. A. Ackerbauer, A. F. Hyderi, S. Hshieh, and U. Elkayam
Comparative Effects of Nesiritide and Nitroglycerin on Renal Function, and Incidence of Renal Injury by Traditional and RIFLE Criteria in Acute Heart Failure
Journal of Cardiovascular Pharmacology and Therapeutics,
March 1, 2012;
17(1):
79 - 85.
[Abstract]
[PDF]
|
|
|
|
|
|
|
J. J. Blinder, S. L. Goldstein, V.-V. Lee, A. Baycroft, C. D. Fraser, D. Nelson, and J. L. Jefferies
Congenital heart surgery in infants: Effects of acute kidney injury on outcomes
J. Thorac. Cardiovasc. Surg.,
February 1, 2012;
143(2):
368 - 374.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
Y.-J. Sheen, J.-L. Lin, I.-T. Lee, Y.-N. Hsu, T.-C. Li, and W. H.-H. Sheu
Low Estimated Glomerular Filtration Rate Is a Major Determinant of Low Ankle-Brachial Index and Toe-Brachial Index in Type 2 Diabetes
Angiology,
January 1, 2012;
63(1):
55 - 61.
[Abstract]
[PDF]
|
|
|
|
|
|
|
J. M. Bourque and G. A. Beller
Stress Myocardial Perfusion Imaging for Assessing Prognosis: An Update
J. Am. Coll. Cardiol. Img.,
December 1, 2011;
4(12):
1305 - 1319.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Albaghdadi, M. Gheorghiade, and B. Pitt
Mineralocorticoid receptor antagonism: therapeutic potential in acute heart failure syndromes
Eur. Heart J.,
November 1, 2011;
32(21):
2626 - 2633.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. M. Testani, S. E. Kimmel, D. L. Dries, and S. G. Coca
Prognostic Importance of Early Worsening Renal Function After Initiation of Angiotensin-Converting Enzyme Inhibitor Therapy in Patients With Cardiac Dysfunction
Circ Heart Fail,
November 1, 2011;
4(6):
685 - 691.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. M. Testani, S. G. Coca, R. P. Shannon, S. E. Kimmel, and T. P. Cappola
Influence of renal dysfunction phenotype on mortality in the setting of cardiac dysfunction: analysis of three randomized controlled trials
Eur J Heart Fail,
November 1, 2011;
13(11):
1224 - 1230.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W.-J. Zhu, M. Nakayama, T. Mori, K. Nakayama, J. Katoh, Y. Murata, T. Sato, S. Kabayama, and S. Ito
Intake of water with high levels of dissolved hydrogen (H2) suppresses ischemia-induced cardio-renal injury in Dahl salt-sensitive rats
Nephrol. Dial. Transplant.,
July 1, 2011;
26(7):
2112 - 2118.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. L. Chow, S. A. O'Barr, J. Peng, E. Chew, F. Pak, R. Quist, P. Patel, J. H. Patterson, and J. T. Heywood
Modulation of Novel Cardiorenal and Inflammatory Biomarkers by Intravenous Nitroglycerin and Nesiritide in Acute Decompensated Heart Failure: An Exploratory Study
Circ Heart Fail,
July 1, 2011;
4(4):
450 - 455.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S.-C. Chen, J.-M. Chang, W.-C. Liu, J.-C. Tsai, L.-I. Chen, M.-Y. Lin, P.-C. Hsu, T.-H. Lin, H.-M. Su, S.-J. Hwang, et al.
Significant correlation between ratio of brachial pre-ejection period to ejection time and left ventricular ejection fraction and mass index in patients with chronic kidney disease
Nephrol. Dial. Transplant.,
June 1, 2011;
26(6):
1895 - 1902.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
A. A. Voors, H. C. Dittrich, B. M. Massie, P. DeLucca, G. A. Mansoor, M. Metra, G. Cotter, B. D. Weatherley, P. Ponikowski, J. R. Teerlink, et al.
Effects of the Adenosine A1 Receptor Antagonist Rolofylline on Renal Function in Patients With Acute Heart Failure and Renal Dysfunction: Results From PROTECT (Placebo-Controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized With Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function)
J. Am. Coll. Cardiol.,
May 10, 2011;
57(19):
1899 - 1907.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Haase, P. Devarajan, A. Haase-Fielitz, R. Bellomo, D. N. Cruz, G. Wagener, C. D. Krawczeski, J. L. Koyner, P. Murray, M. Zappitelli, et al.
The Outcome of Neutrophil Gelatinase-Associated Lipocalin-Positive Subclinical Acute Kidney Injury: A Multicenter Pooled Analysis of Prospective Studies
J. Am. Coll. Cardiol.,
April 26, 2011;
57(17):
1752 - 1761.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Gurgen, B. Hegner, A. Kusch, R. Catar, L. Chaykovska, U. Hoff, V. Gross, T. Slowinski, A. C. da Costa Goncalves, U. Kintscher, et al.
Estrogen Receptor-{beta} Signals Left Ventricular Hypertrophy Sex Differences in Normotensive Deoxycorticosterone Acetate-Salt Mice
Hypertension,
March 1, 2011;
57(3):
648 - 654.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. S. Rogacev, S. Seiler, A. M. Zawada, B. Reichart, E. Herath, D. Roth, C. Ulrich, D. Fliser, and G. H. Heine
CD14++CD16+ monocytes and cardiovascular outcome in patients with chronic kidney disease
Eur. Heart J.,
January 1, 2011;
32(1):
84 - 92.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
S. Anderson, B. Eldadah, J. B. Halter, W. R. Hazzard, J. Himmelfarb, F. M. Horne, P. L. Kimmel, B. A. Molitoris, M. Murthy, A. M. O'Hare, et al.
Acute Kidney Injury in Older Adults
J. Am. Soc. Nephrol.,
January 1, 2011;
22(1):
28 - 38.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
D. Scrutinio, A. Passantino, D. Santoro, and R. Catanzaro
The cardiorenal anaemia syndrome in systolic heart failure: prevalence, clinical correlates, and long-term survival
Eur J Heart Fail,
January 1, 2011;
13(1):
61 - 67.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. G. Bongartz, B. Braam, M. C. Verhaar, M. J. M. Cramer, R. Goldschmeding, C. A. Gaillard, P. Steendijk, P. A. Doevendans, and J. A. Joles
The nitric oxide donor molsidomine rescues cardiac function in rats with chronic kidney disease and cardiac dysfunction
Am J Physiol Heart Circ Physiol,
December 1, 2010;
299(6):
H2037 - H2045.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
I. Sipahi and J. C. Fang
Treating Heart Failure on Dialysis: Finally Getting Some Evidence
J. Am. Coll. Cardiol.,
November 16, 2010;
56(21):
1709 - 1711.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. P. E. Lassus, M. S. Nieminen, K. Peuhkurinen, K. Pulkki, K. Siirila-Waris, R. Sund, V.-P. Harjola, and for the FINN-AKVA study group
Markers of renal function and acute kidney injury in acute heart failure: definitions and impact on outcomes of the cardiorenal syndrome
Eur. Heart J.,
November 2, 2010;
31(22):
2791 - 2798.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
J. Butler, D. Chirovsky, H. Phatak, A. McNeill, and R. Cody
Renal Function, Health Outcomes, and Resource Utilization in Acute Heart Failure: A Systematic Review
Circ Heart Fail,
November 1, 2010;
3(6):
726 - 745.
[Full Text]
[PDF]
|
|
|
|
|
|
|
J.-M. Sinning, A. Ghanem, H. Steinhauser, V. Adenauer, C. Hammerstingl, G. Nickenig, and N. Werner
Renal Function as Predictor of Mortality in Patients After Percutaneous Transcatheter Aortic Valve Implantation
J. Am. Coll. Cardiol. Intv.,
November 1, 2010;
3(11):
1141 - 1149.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. M. Felker and A. S. Maisel
A Global Rank End Point for Clinical Trials in Acute Heart Failure
Circ Heart Fail,
September 1, 2010;
3(5):
643 - 646.
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. van der Putten, K. E. Jie, D. van den Broek, R. J. Kraaijenhagen, C. Laarakkers, D. W. Swinkels, B. Braam, and C. A. Gaillard
Hepcidin-25 is a marker of the response rather than resistance to exogenous erythropoietin in chronic kidney disease/chronic heart failure patients
Eur J Heart Fail,
September 1, 2010;
12(9):
943 - 950.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. B. Rodrigues, R. G. Bruetto, U. S. Torres, A. P. Otaviano, D. M. T. Zanetta, and E. A. Burdmann
Effect of Kidney Disease on Acute Coronary Syndrome
Clin. J. Am. Soc. Nephrol.,
August 1, 2010;
5(8):
1530 - 1536.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
P. A. McCullough, M. Haapio, S. Mankad, N. Zamperetti, B. Massie, R. Bellomo, T. Berl, S. D. Anker, I. Anand, N. Aspromonte, et al.
Prevention of cardio-renal syndromes: workgroup statements from the 7th ADQI Consensus Conference
Nephrol. Dial. Transplant.,
June 1, 2010;
25(6):
1777 - 1784.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Haase, R. Bellomo, and A. Haase-Fielitz
Novel Biomarkers, Oxidative Stress, and the Role of Labile Iron Toxicity in Cardiopulmonary Bypass-Associated Acute Kidney Injury
J. Am. Coll. Cardiol.,
May 11, 2010;
55(19):
2024 - 2033.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Ronco, P. McCullough, S. D. Anker, I. Anand, N. Aspromonte, S. M. Bagshaw, R. Bellomo, T. Berl, I. Bobek, D. N. Cruz, et al.
Cardio-renal syndromes: report from the consensus conference of the Acute Dialysis Quality Initiative
Eur. Heart J.,
March 2, 2010;
31(6):
703 - 711.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. M. Felker, P. S. Pang, K. F. Adams, J. G. F. Cleland, G. Cotter, K. Dickstein, G. S. Filippatos, G. C. Fonarow, B. H. Greenberg, A. F. Hernandez, et al.
Clinical Trials of Pharmacological Therapies in Acute Heart Failure Syndromes: Lessons Learned and Directions Forward
Circ Heart Fail,
March 1, 2010;
3(2):
314 - 325.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. G. Bongartz, B. Braam, M. C. Verhaar, M. J. Cramer, R. Goldschmeding, C. A. Gaillard, P. A. Doevendans, and J. A. Joles
Transient nitric oxide reduction induces permanent cardiac systolic dysfunction and worsens kidney damage in rats with chronic kidney disease
Am J Physiol Regulatory Integrative Comp Physiol,
March 1, 2010;
298(3):
R815 - R823.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
W. H. W. Tang and W. Mullens
Cardiorenal syndrome in decompensated heart failure
Heart,
February 1, 2010;
96(4):
255 - 260.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. M. Givertz
Adenosine A1 Receptor Antagonists at a Fork in the Road
Circ Heart Fail,
November 1, 2009;
2(6):
519 - 522.
[Full Text]
[PDF]
|
|
|
|
|
|
|
G. M. London and B. Pannier
Renal replacement therapy for heart failure patients: in whom, when and which therapy to use?
Nephrol. Dial. Transplant.,
August 1, 2009;
24(8):
2314 - 2315.
[Full Text]
[PDF]
|
|
|
|
|
|
|
L. A. Allen, A. F. Hernandez, C. M. O'Connor, and G. M. Felker
End Points for Clinical Trials in Acute Heart Failure Syndromes
J. Am. Coll. Cardiol.,
June 16, 2009;
53(24):
2248 - 2258.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
F. G. Hage, R. Venkataraman, G. J. Zoghbi, G. J. Perry, A. M. DeMattos, and A. E. Iskandrian
The Scope of Coronary Heart Disease in Patients With Chronic Kidney Disease
J. Am. Coll. Cardiol.,
June 9, 2009;
53(23):
2129 - 2140.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
K. van der Putten, L. G. Bongartz, B. Braam, and C. A.J.M. Gaillard
The Cardiorenal Syndrome: A Classification Into 4 Groups?
J. Am. Coll. Cardiol.,
April 14, 2009;
53(15):
1340 - 1340.
[Full Text]
[PDF]
|
|
|
|
|
|
|
C. Ronco, M. Haapio, A. A. House, N. Anavekar, and R. Bellomo
Reply
J. Am. Coll. Cardiol.,
April 14, 2009;
53(15):
1340 - 1341.
[Full Text]
[PDF]
|
|
|
|
|
|
|
M. Jessup and M. R. Costanzo
The Cardiorenal Syndrome: Do We Need a Change of Strategy or a Change of Tactics?
J. Am. Coll. Cardiol.,
February 17, 2009;
53(7):
597 - 599.
[Full Text]
[PDF]
|
|
|
|
