New aspects in cardiorenal syndrome and HFpEF

Abstract

Cardiorenal syndrome (CRS) is a complex disease in which the heart and kidneys are simultaneously affected, and subsequently, the malfunction of one organ promotes the deterioration of the other. Heart failure (HF) with preserved ejection fraction (HFpEF) is the most common form of HF. The pathophysiology of CRS is not well known and several mechanisms have been proposed. An elevation of central venous pressure seems to be one of the key points to consider, among others such as an increase in intraabdominal pressure. Several diagnostic tools have been identified to establish the diagnosis of CRS in patients with HFpEF. Currently, the availability of biomarkers of renal and cardiac injury, the use of pulmonary ultrasound, the monitoring of the size of the inferior vena cava and the study of the renal venous pattern offer a new dimension in accurately diagnosing and quantifying organ damage in CRS. Beyond the symptomatic treatment of congestion, until recently specific therapeutic tools for patients with CRS and HFpEF were not available. Interestingly, the development of new drugs such as the angiotensin/neprilysin inhibitors and sodium-glucose cotransporter-2 (SGLT-2) inhibitors offer new therapeutic strategies with potential benefits in reduction of cardiorenal adverse outcomes in this population. Randomized clinical trials that focus on patients with HFpEF are currently ongoing to delineate optimal new treatments that may be able to modify their prognosis. In addition, multidisciplinary teamwork (nephrologist, cardiologist and nurse) is expected to decrease the number of visits and the rate of hospitalizations, with a subsequent patient benefit.

Keywords: AKI; cardiorenal syndrome; chronic renal failure; diuretics; heart failure.

FIGURE 1:

Estimated prevalence of CKD. CKD, chronic kidney disease; HF, heart failure; CRS, cardiorenal syndrome; HFpEF, heart failure with preserved ejection fraction.

FIGURE 2:

Suggested algorithm for CRS diagnosis. HfpEF, heart failure with preserved ejection fraction; CRS, cardiorenal syndrome; eGFR, estimated glomerular filtration rate; LA, left atria; TR, tricuspid regurgitation; SR, sinus rhythm; AF, atrial fibrillation; NTproBNP, N-terminal prohormone of brain natriuretic peptide; CA-125, cancer antigen 125.

FIGURE 3:

Suggested algorithm for CRS treatment. HFpEF, heart failure with preserved ejection fraction; CRS, cardiorenal syndrome; IRVF, intrarenal venous flow; CVP, central venous pressure; SGLTi, sodium-glucose co-transporter 2 inhibitors; MRA, mineralocorticoid receptor antagonists; RRT, renal replacement therapy; IVC, inferior vena cava; LA, left atria.