2. What is a Syndrome?
Definition: A group of symptoms that
consistently occur together or a condition
characterized by a set of associated symptoms.
3. Cardiorenal Syndrome (CRS)
Type 1: Acute CRS
Type 2: Chronic CRS
Type 3: Acute Renocardiac Syndrome
Type 4: Chronic Renocardiac Syndrome
Type 5: Secondary CRS
4. Patient Case
● 55 y/o female
● CC: Ongoing chest pain, SOB, leg swelling
● HPI: Presented to the ED with complaints of ongoing
chest pain and SOB over several weeks. She noticed
swelling in her lower extremities.
● PMH: MI 2008, s/p PCI with 2 stents, CAD, s/p 3V
CABG 2010, T2DM, HTN, HLD, Diastolic HF
● PE: Elevated JVP 17 cm, skin taut over LE and very
tender to palpation, lungs with crackles
5. Patient Case
● Labs: BUN: 68, Scr: 4.24 (Stage IV CKD GFR 15-29)
● BNP 404, Alb: 3.4, O2 Sat: 92% on RA
● Weight: 123 kg, baseline wt 110 kg
● Medications
● Amlodipine 10 mg qd
● Aspirin 81 mg qd
● Metoprolol 100 mg daily
● Labetalol 300 mg qAM/
Labetalol 450 mg qPM
● Imdur 240 mg qd
● Fenofibrate 200 mg qd
● Prasugrel 10 mg qd
● Lovoza 2 gram BID
● Rosuvastatin 40 mg qd
● Ezetimibe 10 mg qd
● Torsemide 100 mg qd
● Bicitra 15 ml TID
● Lantus 25 units BID
● Lispro 25 units TID
Patient Case
6. Type 1: Acute CRS
● Acute heart failure leading to acute kidney
injury (AKI)
● Impaired LVEF-->more severe AKI-->HF
treatment issues
○ Limited use of ACEIs, ARBs, and aldosterone
antagonists in AKI
○ Decreased diuretic response
○ Avoid beta blockers
7. Diagnostic Markers of AKI
● Early diagnosis is desired
● Neutrophil gelatinase-associated lipocalin
(NGAL)
● Cystatin C
8. Taub P, Borden K, Fard A, and Maisel A. Role of biomarkers in the diagnosis and prognosis of
acute kidney injury in patients with cardiorenal syndrome. Expert Rev Cardiovasc Ther. [Internet].
2012 May [cited 2014 Aug 22]. 10(5):657-67. DOI: 10.1586/erc.12.2
9. Type 2: Chronic CRS
● Chronic CHF leading to worsening CKD
● Pathophysiology of renal dysfunction in the setting
of advanced HF is limited.
○ No association between LVEF and est. GFR has been
consistently shown
○ Patients are more likely to be receiving loops and vasodilators
compared to patients with stable renal function.
● ESAs have not been shown to provide any benefit in
CHF.
10. Ronco C, Haapio M,
House A, Anavekar N,
and Bellomo R.
Cardiorenal Syndrome.
J Am Coll Cardiol
[Internet]. 2008 Nov 4
[cited 2014 Aug 20]. 52
(19):1527-39.
11. Type 3: Acute Renocardiac Syndrome
● Acute worsening of kidney function leading to acute
cardiac dysfunction.
● 5 Pathways
○ Fluid overload
○ Hyperkalemia
○ Untreated uremia
○ Acidemia
○ Renal ischemia
12. Ronco C, Haapio
M, House A,
Anavekar N, and
Bellomo R.
Cardiorenal
Syndrome. J Am
Coll Cardiol
[Internet]. 2008
Nov 4 [cited 2014
Aug 20]. 52(19):
1527-39.
13. Type 4: Chronic Renocardiac Syndrome
● Primary CKD contributing to decreased
cardiac function and increased risk of
adverse cardiac events.
● Less CKD patients receive appropriate meds.
● More than 50% of deaths in CKD Stage 5
cohorts are attributed to CVD.
14. Ronco C, Haapio M, House
A, Anavekar N, and
Bellomo R. Cardiorenal
Syndrome. J Am Coll
Cardiol [Internet]. 2008
Nov 4 [cited 2014 Aug 20].
52(19):1527-39.
15. Type 5: Secondary CRS
● Combined cardiac and renal dysfunction due
to acute or chronic conditions.
● Sepsis, diabetes, amyloidosis, SLE and
sarcoidosis can contribute to Type 5.
16. Back to our patient case...
● What type of CRS do you think she has?
○ History of diastolic heart failure with an elevated Scr
2.0 at baseline.
○ Presented to the ED with HF exacerbation and fluid
overload. Scr increased to 4.2.
17. References
● Maisel A, Mueller C, Fitzgerald R, Brikhan R, Hiestand B, Iqbal N, Clopton P and van Veldhuisen D. Prognostic
utility of plasma neutrophil gelatinase-associated lipocalin in patients with acute heart failure: The NGAL
EvaLuation Along with B-type NaTriuretic Peptide in acutely decompensated heart failure (GALLANT) trial
[Internet]. European Journal of heart Failure. 2011 May 9 [cited 2014 Aug 20]. 13: 846-51. DOI:10.1093
/eurjhf/hfr087.
● Ronco C, Haapio M, House A, Anavekar N, and Bellomo R. Cardiorenal Syndrome. J Am Coll Cardiol [Internet].
2008 Nov 4 [cited 2014 Aug 20]. 52(19):1527-39. Available from Http://content.onlinejacc.org. DOI: 10.1016/j.
jacc.2008.07.051
● Taub P, Borden K, Fard A, and Maisel A. Role of biomarkers in the diagnosis and prognosis of acute kidney
injury in patients with cardiorenal syndrome. Expert Rev Cardiovasc Ther. [Internet]. 2012 May [cited 2014 Aug
22]. 10(5):657-67. DOI: 10.1586/erc.12.26
