- Open Access
Renocardiac syndromes: physiopathology and treatment stratagems
© Kingma et al. 2015
- Received: 15 April 2015
- Accepted: 24 August 2015
- Published: 16 October 2015
Purpose of review
Bidirectional inter-organ interactions are essential for normal functioning of the human body; however, they may also promote adverse conditions in remote organs. This review provides a narrative summary of the epidemiology, physiopathological mechanisms and clinical management of patients with combined renal and cardiac disease (recently classified as type 3 and 4 cardiorenal syndrome). Findings are also discussed within the context of basic research in animal models with similar comorbidities.
Sources of information
Pertinent published articles were identified by literature search of PubMed, MEDLINE and Google Scholar. Additional data from studies in the author’s laboratory were also consulted.
The prevalence of renocardiac syndrome throughout the world is increasing in part due to an aging population and to other risk factors including hypertension, diabetes and dyslipidemia. Pathogenesis of this disorder involves multiple bidirectional interactions between the kidneys and heart; however, participation of other organs cannot be excluded. Our own work supports the hypothesis that the uremic milieu, caused by kidney dysfunction, produces major alterations in vasoregulatory control particularly at the level of the microvasculature that results in impaired oxygen delivery and blood perfusion.
Recent clinical literature is replete with articles discussing the necessity to clearly define or characterize what constitutes cardiorenal syndrome in order to improve clinical management of affected patients. Patients are treated after onset of symptoms with limited available information regarding etiology. While understanding of mechanisms involved in pathogenesis of inter-organ crosstalk remains a challenging objective, basic research data remains limited partly because of the lack of animal models.
Preservation of microvascular integrity may be the most critical factor to limit progression of multi-organ disorders including renocardiac syndrome. More fundamental studies are needed to help elucidate physiopathological mechanisms and for development of treatments to improve clinical outcomes.
Objectifs de la révision
Les interactions bidirectionnelles entre organes adjacents sont essentielles au bon fonctionnement du corps humain mais sont aussi susceptibles de provoquer des conditions adverses sur des organes plus éloignés. Cette revue offre un compte rendu sommaire de l’épidémiologie, des mécanismes physiopathologiques et du traitement clinique des patients atteints à la fois d’insuffisance rénale et de cardiopathie, ou tel que récemment désignés, atteints du syndrome cardiorénal de type 3 ou de type 4. La revue examine également des résultats obtenus en recherche fondamentale en utilisant des modèles animaux présentant des cas similaires de comorbidité.
Les articles pertinents ont été répertoriés à la suite d’une recherche dans la littérature sur PubMed, MEDLINE et « Google Scholar ». Des données complémentaires provenant d’études du laboratoire de recherche de l'auteur ont aussi été consultées.
Le vieillissement de la population en plus de facteurs de risque incluant l’hypertension, le diabète et la dyslipidémie augmente en partie la prévalence du syndrome cardiorénal à travers le monde. La pathogenèse de ce désordre implique de multiples interactions bidirectionnelles entre le cœur et les reins; cependant, la participation d’organes périphériques n’est tout de même pas à exclure. Nos travaux soutiennent l’hypothèse selon laquelle l’environnement urémique résultant de la dysfonction rénale serait responsable d’altérations majeures dans la régulation de la pression, particulièrement au niveau des microvaisseaux. En résultent une perfusion sanguine altérée et une distribution insuffisante d’oxygène vers les organes.
Limites de l’étude
La littérature clinique récente comporte de nombreux articles traitant de la nécessité d’identifier et de caractériser de façon plus élaborée les causes du syndrome cardiorénal dans la perspective d’améliorer le traitement clinique des patients qui en sont atteints. Par contre, puisqu’il existe encore très peu d’informations sur l’étiologie du syndrome cardiorénal, les patients ne sont pris en charge qu’après son apparition. Qui plus est, la compréhension des mécanismes impliqués dans la pathogenèse résultant des interactions entre organes demeure un objectif difficile à atteindre, en partie parce que la recherche fondamentale est limitée étant donné la rareté des modèles animaux pour cette pathologie.
À la lumière des données disponibles à ce jour, il apparait que la préservation de l’intégrité du système vasculaire, particulièrement au niveau des microvaisseaux, est un facteur-clé pour restreindre le développement de désordres impliquant plusieurs organes tel le syndrome cardiorénal. Davantage d’études en recherche fondamentale sont requises pour faire la lumière sur les mécanismes physiopathologiques de ce syndrome et développer des traitements efficaces pour en améliorer les résultats cliniques.
- Acute Kidney Injury
- Acute Decompensated Heart Failure
- Renal Denervation
- Acute Kidney Injury Network
Co-existence of kidney and cardiac disorders is increasingly prevalent throughout the world. A major consequence of failing kidneys is the stimulation of metabolic and humoral pathways that cause injury to remote organs; a similar scenario occurs with disorders of other organs such as the heart and liver. Mechanisms responsible for disease progression, regardless of the organ initially affected, are complex; understanding the mechanisms and pathways involved in, or responsible for inter-organ crosstalk, is a growing area of research interest. Clinical management of cardiorenal syndrome patients is particularly complex due to the involvement of multiple organs and the difficulty in targeting specific symptoms.
Herein, we review recent advances concerning physiopathology, therapeutic interventions and complications of renocardiac syndrome. Recent data, including our own, from animal models are discussed here; primary focus is on the impact of acute kidney injury on systemic hemodynamics, blood flow regulation and endothelial function. Novel therapies that target the microcirculation could benefit renocardiac syndrome patients and improve mortality.
Cardiorenal syndrome classification
Type 1 (acute cardio-renal syndrome)
Abrupt deterioration of cardiac function that results in acute kidney injury (AKI)
Type 2 (chronic cardio-renal syndrome)
Chronic abnormalities of cardiac function leading to progressive chronic kidney disease (CKD)
Type 3 (acute reno-cardiac syndrome)
Abrupt and primary worsening of kidney function that initiates acute cardiac dysfunction
Type 4 (chronic reno-cardiac syndrome)
CKD that promotes reduction of cardiac function
Type 5 (secondary CRS)
Systemic disorders that impair both cardiac and renal function
Herein, we provide a narrative review of clinical and basic science literature on renocardiac syndrome (type 3 and type 4 CRS) with regard to epidemiology, pathogenesis and clinical interventions designed to improve outcomes. Clinical and basic science reports were searched using MEDLINE and PubMed with the keywords reno-cardiac syndrome, kidney disease, heart disease and combinations thereof.
Type 3 CRS is usually triggered by an episode of acute kidney injury (AKI); nephrons are particularly sensitive to ischemia and blood borne toxins. AKI is often superimposed on chronic renal disease and could be a necessary precursor of end-stage renal disease. Elucidation of mechanisms remains difficult due to the complex interplay between chronic and acute kidney disease phenotypes . Acute worsening of kidney function ultimately produces cardiac dysfunction (i.e. acute decompensated heart failure, acute myocardial infarction and arrhythmias) . The overall incidence of AKI in the general population appears to be increasing  based on Risk, Injury, Failure, Loss, End-stage kidney disease classification (RIFLE)/Acute kidney injury network (AKIN) criteria  that use change in serum creatinine and urinary output as primary markers of kidney dysfunction.
Type 4 CRS, on the other hand, involves chronic abnormalities of renal function due in part to aging, diabetes, hypertension and dyslipidemia that progresses to multi-organ disease  possibly due to toxic effects of elevated uremia levels. Cardiovascular disease is highly prevalent in these patients and accounts for the majority of cardiac-related deaths (secondary to ischemia) .
Risk factors for AKI
Renal artery stenosis (ischemia-reperfusion injury)
Surgical interventions (including anesthesia)
Intrinsic/extrinsic ureteral obstruction
Infection (gastroenteritis, etc.)
Drug-related complications (pharmacologic toxicity, drug-abuse, etc.)
Possible risk factors for CKD
AKI (all cause)
Hypertension, cardiovascular and hepatic disease
Age, gender, race
Studies of the physiopathological evolution of kidney injury, either acute or chronic, in humans are rare possibly because of the common misconception that tubular regeneration occurs in patients after AKI [35–38]. This is based primarily on evidence of normalisation of serum creatinine levels. Potential mechanisms for Type 3 and 4 CRS are categorized on the basis of hemodynamic or non-hemodynamic criteria .
Cardio-renal interactions are generally explained using extracellular fluid volume homeostasis and blood pressure control criteria . Consequences of heart failure including reduced cardiac output and blood pressure stimulate both the sympathetic nervous and renin-angiotensin systems which results in volume expansion; [40, 41] the latter allows restoration of renal perfusion. Data for kidney hemodynamics and segmental sodium handling are limited for patients with combined heart and renal failure. However, bi-directional coupling between dysfunctional heart and kidneys induces sodium and water retention that ultimately exacerbates heart failure by affecting arterial pressure (lower) and renal venous pressure (higher). Treatment success rates in patients presenting with heart and kidney failure is mitigated. Additional data on the role of hemodynamic factors in progression of acute and chronic renocardiac syndrome can be obtained in animal models where the relation between renal venous pressure, renal blood flow,  intra-tubular pressure [43, 44] and glomerular filtration rate  has been established.
In addition to the proposed hemodynamic factors, various cardiorenal connectors may activate endogenous systems after AKI and contribute to progression of symptoms. These include, but are not limited to, the sympathetic nervous, renin-angiotensin aldosterone and coagulation systems,  inflammation, oxidative stress and nitric oxide equilibrium.
For type 3 CRS, AKI (due to acute arterial ischemia-reperfusion injury, or other causes) produces rapid and significant functional changes in the heart characterized by LV dilatation and alterations of various functional parameters including LV relaxation time, fractional shortening and end-systolic and end-diastolic fractional shortening. Cardiocyte apoptosis has been suggested to play a role in promoting these changes along with stimulation of inflammatory mediators. Ischemia initiates a cascade of inflammation that is crucial to organ repair and if unchecked, eventual deterioration of organ function. In rodent models of acute and chronic kidney disease, the role of inflammation is predominant as evidenced by greater secretion of pro-inflammatory cytokines and infiltration of inflammatory cell types [47, 48]. The neuroendocrine system also plays an important role in physiopathology of type 3 CRS; complex pathways are activated after onset of AKI resulting in activation of the systemic nervous and renin-angiotensin systems. While activation of the systemic nervous system initially protects cardiac output it also appears to stimulate apoptosis,  neointimal formation and affects immune system function . In addition, activation of the renin angiotensin system stimulates renin secretion by the kidneys; it also leads to dysregulation of extracellular fluid volume and vasoconstriction which can exacerbate the effects of ischemia by limiting adequate oxygen delivery.
Mechanisms involved in type 4 CRS are multi-faceted and invariably shared by different organs because of vascular disease and endothelial dysfunction as well as the cumulative toxic influences of uremia. A plethora of risk factors in these patients contributes to progression of cardiac and kidney failure; unique risks are also associated with dialysis procedures particularly in patients with end-stage renal disease . A recent review by House provides an exclusive summary of potential mechanisms . The role of the uremic milieu in development of multi-organ dysfunction still needs to be appraised; specific uremic toxins (guanidines, phenols, parathyroid hormone, proinflammatory cytokines, etc.), or combinations thereof, could directly cause metabolic and physiologic derangements and contribute to progression of the disease phenotype. In patients with congestive heart failure and progressive renal insufficiency, pressure and volume overload result in augmented cardiac work and compensatory hypertrophy (in part due to cardiac and renal fibrosis). Under these conditions oxygen delivery to enlarged myocytes is compromised due to vascular remodeling at the level of the microvasculature; this focal underperfusion or maldistribution of blood aggravates cellular injury.
Continued investigation to determine the physiopathological mechanisms involved in development of renal disease after AKI will require a multifaceted and bidirectional approach. Identification of risk factors involved in early kidney injury might be the most logical approach to prevent and delay adverse outcomes;  as stated earlier, vascular remodeling in the presence of uremic toxins increases oxidative stress, inflammation and lipid metabolism that exacerbates endothelial dysfunction. Thus, prevention of early microvascular dysfunction may be fundamental to limiting adverse effects of progressive kidney and heart disorders.
Chuasuwan and Kellum recently reviewed different treatment strategies specific to the kidneys and heart based on RIFLE and AKIN criteria  that establish different severity levels for AKI to enable prediction of outcomes in affected patients. In high risk patients, potentially nephrotoxic drugs must be avoided and efforts should be directed to maintaining arterial pressure and preventing volume overload. Three stages (risk, injury, failure) of AKI were proposed. For stage 1 AKI patients, kidney function should be closely monitored (i.e. using non-invasive diagnostic evaluations). Stage 2 AKI presents particular challenges due to elevated risk of mortality; fluid, electrolyte and acid–base homeostasis is of particular concern. Stage 3 AKI is the most severe and life-threatening and often requires extracorporeal kidney support or renal replacement. Treatment strategies for the heart in type 3 CRS pose a particular challenge; prevention of LV volume overload is fundamental to limit the potential for worsening cardiac and renal function. Use of diuretics to improve clinical symptoms in heart failure patients is the status quo; however, evidence of a mortality benefit in patients with AKI remains controversial [58–60]. Indeed, use of diuretics for AKI is contra-indicated except for management of volume overload [61, 62]. Clinical outcomes are also improved using ultrafiltration and hemofiltration to reduce volume overload in patients that are refractory to diuretics.
Type 4 CRS patient management requires a multidisciplinary approach because of the bidirectional, multifaceted physiopathology of this syndrome; treatment strategies are mostly targeted to risk factors such as anemia, hypertension and malnutrition [63, 64]. However, for the most part , no specific treatment provides unequivocal benefit since targeted risk factors comprise only a small fraction of the physiopathological puzzle. As such, a combination therapy approach is probably needed to limit the devastating effects of this syndrome.
While there is no consensus for pharmacological management of Type 3 or 4 CRS patients, there is general agreement that more evidence-based clinical studies are necessary. Numerous inotropes and vasodilators including neurohormonal antagonists and diuretics have been evaluated on the basis of their ability to increase urine output and glomerular filtration and lower serum creatinine (see recent review by Kim ). Modest improvement of kidney function and survival (OPTIME-HF ) has been reported with milrinone in acute decompensated heart failure patients; renal perfusion has been shown to be worse in acute renal failure patients given dopamine alone . On the other hand, combined low-dosages of dopamine/furosemide appear to be more useful due to improved renal function and potassium homeostasis (DAD-HF ). Promising results with regard to glomerular filtration have also been shown with the calcium sensitizing phosphodiesterase inhibitor, levosimendan (SURVIVE ), but its overall usefulness in patients with acute heart failure remains to be established and questions persist regarding their ability to improve kidney function and long-term survival. Vasopressin antagonists reduce symptoms in patients with hyponatremia and oliguria (EVEREST ) and adenosine receptor blockers improve kidney function. On the other hand, several clinical trials (PROTECT , REACH-UP ) report no functional benefit.
Angiotensin converting enzyme inhibitors could also improve clinical outcomes (CONSENSUS ) but it is recommended that they be used cautiously. Mineralocorticoid receptor blockers that markedly improve clinical outcomes in heart failure patients (RALES , EPHESUS ) are contra-indicated when renal dysfunction is present due to the elevated risk of hyperkalemia. Statins appear to reduce all-cause mortality in mild to moderate chronic kidney disease patients but may be ineffective in end-stage renal disease . Reduced albuminuria that has been reported in rodents [77, 78] treated with statins affords significant renal protection; however, clinical findings on this question remain divided [79–81].
Non-pharmacologic treatments currently under investigation in clinical and animal studies also include renal denervation and remote conditioning. Renal denervation has been studied over the past 25 years to counter the effects of elevated renal sympathetic activity which 1-stimulates beta-1 receptors in the juxtaglomerular apparatus to increase renin release, 2- acts on alpha-1B receptors of the collecting ducts to increase sodium reabsorption and 3- acts on alpha-1A receptors of renal vasculature to promote vasoconstriction .
Renal afferent nerves transmit sensory information to the central nervous system from chemo- and mechanoreceptors in the kidneys; activation of renal afferent nerves is sympathoinhibitory in normal animals. Renal efferent nerves mediate changes in kidney function via innervation of all essential renal structures (renal vessels, tubules, juxtaglomerular apparatus);  activation of these nerves results in water retention, sodium reabsorption, reduced blood flow and activation of the renin-angiotensin-aldosterone system. Sympathoexcitatory reflexes are dominant in patients with resistant hypertension and CKD but the mechanisms involved in renal afferent activation are yet to be established. Renal nerves could play a role in renal inflammation and injury; suggested mechanisms include β-adrenergic receptor activation (causing podocyte injury), release of neuropeptides (neuropeptide Y, vasoactive intestinal polypeptide, substance P, etc.) that contribute to neuroimmune interactions, renin release from juxtaglomerular cells (increases plasma angiotensin II levels) and other pro-inflammatory cytokines including tumor necrosis factor and IL-1β from immune cells. Renal denervation has also been postulated to reduce kidney injury by improving blood glucose levels . Findings from animal studies indicate that renal denervation mitigates inflammation and kidney injury;  however the results of clinical trials are inconsistent.
Two clinical trials, Simplicity HTN-1 and HTN-2 , report sustained reduction of blood pressure in patients with resistant hypertension and preserved renal function;  however, these beneficial effects were not observed in patients from the Simplicity HTN-3 trial . Variability between studies with regard to renoprotection by renal denervation is probably related to differences in study design and primary endpoints. However, interventions on renal nerves merit further investigation for clinical management of hypertension and heart failure (i.e. major components of type 4 CRS phenotype). Interestingly, renal denervation may not be applicable in patients with AKI; numerous questions remain unanswered regarding the role of renal nerves in progression of acute renocardiac syndrome.
Remote conditioning stratagems (per-, pre- and post-conditioning) are the subject of a number of ongoing clinical trials (cf. ClinicalTrials.gov); numerous animal investigations have reported significant protection of vulnerable organs against ischemic injury by remote conditioning [89–93]. Ischemic tolerance of organs such as the heart may be reduced in the presence of co-morbidities; [32, 33, 94] larger myocardial infarcts occur in patients with chronic kidney disease and may account for higher mortality. In uremic rodents subject to different conditioning protocols significant protection against ischemic injury was observed;  similarly in a porcine model of AKI remote conditioning afforded marked renoprotective effects . Remote limb-ischemia has also been shown to alleviate contrast medium induced renal injury in patients with moderate kidney disease  and even improved kidney function when performed prior to kidney transplantation in patients . Whether organ conditioning stratagems could be useful in patients with acute renocardiac syndrome warrants further investigation;  patients with moderate chronic kidney disease have been reported to respond to remote conditioning . These positive findings may be critical to improve outcomes in patients subject to renal replacement therapies. Ongoing clinical trials (The Context trial, clinicaltrials.gov NCT01395719, and the REPAIR Trial, ISRCTN30083294) should provide additional data regarding the potential usefulness of conditioning strategems for patients with renocardiac syndrome.
Bi-directional communication between the heart and kidneys occurs through various pathways that, in healthy subjects, modulate cardiac output, vessel tone, volume status and excretion of metabolic waste compounds. It is increasingly apparent that pathological changes in one organ can instigate the release of a cascade of mediators that promote secondary dysfunction or injury in another distant organ. Further controlled clinical and more robust fundamental research is necessary to clarify existing contradictory findings and to improve understanding of mechanisms responsible for development of inter-organ pathologies.
None, no funding source was involved.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Damman K, Testani JM. The kidney in heart failure: an update. Eur Heart J. 2015;36(23):1437-1444. Google Scholar
- Maxwell MH, Breed ES, Schwartz IL. Renal venous pressure in chronic congestive heart failure. J Clin Invest. 1950;29:342–8.PubMed CentralView ArticlePubMedGoogle Scholar
- Heywood JT. The cardiorenal syndrome: lessons from the ADHERE database and treatment options. Heart Fail Rev. 2004;9:195–201.View ArticlePubMedGoogle Scholar
- Shlipak MG, Massie BM. The clinical challenge of cardiorenal syndrome. Circulation. 2004;110:1514–7.View ArticlePubMedGoogle Scholar
- Braam B, Joles JA, Danishwar AH, Gaillard CA. Cardiorenal syndrome--current understanding and future perspectives. Nat Rev Nephrol. 2014;10:48–55.View ArticlePubMedGoogle Scholar
- Ronco C, McCullough P, Anker SD, Anand I, Aspromonte N, Bagshaw SM, et al. Cardio-renal syndromes: report from the consensus conference of the acute dialysis quality initiative. Eur Heart J. 2010;31:703–11.PubMed CentralView ArticlePubMedGoogle Scholar
- Bonventre JV. Mechanisms of acute kidney injury and repair. In: Jorres A, Ronco C, Kellum JA, editors. Management of Acute Kidney Problems. Berlin, Heidelberg: Springer; 2010. p. 13–20.View ArticleGoogle Scholar
- Chuasuwan A, Kellum JA. Cardio-renal syndrome type 3: epidemiology, pathophysiology, and treatment. Semin Nephrol. 2012;32:31–9.View ArticlePubMedGoogle Scholar
- Joannidis M, Metnitz PG. Epidemiology and natural history of acute renal failure in the ICU. Crit Care Clin. 2005;21:239–49.View ArticlePubMedGoogle Scholar
- Bagshaw SM, Cruz DN, Aspromonte N, Daliento L, Ronco F, Sheinfeld G, et al. Epidemiology of cardio-renal syndromes: workgroup statements from the 7th ADQI Consensus Conference. Nephrol Dial Transplant. 2010;25:1406–16.View ArticlePubMedGoogle Scholar
- House AA, Anand I, Bellomo R, Cruz D, Bobek I, Anker SD, et al. Definition and classification of Cardio-Renal Syndromes: workgroup statements from the 7th ADQI Consensus Conference. Nephrol Dial Transplant. 2010;25:1416–20.View ArticlePubMedGoogle Scholar
- Cheung AK, Sarnak MJ, Yan G, Berkoben M, Heyka R, Kaufman A, et al. Cardiac diseases in maintenance hemodialysis patients: results of the HEMO Study. Kidney Int. 2004;65:2380–9.View ArticlePubMedGoogle Scholar
- 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;12:861–5.View ArticlePubMedGoogle Scholar
- de Abreu KL, Silva Junior GB, Barreto AG, Melo FM, Oliveira BB, Mota RM, et al. Acute kidney injury after trauma: Prevalence, clinical characteristics and RIFLE classification. Indian J Crit Care Med. 2010;14:121–8.PubMed CentralView ArticlePubMedGoogle Scholar
- Pavan M. Incidence of acute cardiorenal syndrome type 3 in India. Iran J Kidney Dis. 2014;8:42–5.PubMedGoogle Scholar
- Liano F, Junco E, Pascual J, Madero R, Verde E. The spectrum of acute renal failure in the intensive care unit compared with that seen in other settings. The Madrid Acute Renal Failure Study Group. Kidney Int Suppl. 1998;66:S16–24.PubMedGoogle Scholar
- Varrier M, Ostermann M. Novel risk factors for acute kidney injury. Curr Opin Nephrol Hypertens. 2014;23:560–9.View ArticlePubMedGoogle Scholar
- Ryden L, Sartipy U, Evans M, Holzmann MJ. Acute kidney injury after coronary artery bypass grafting and long-term risk of end-stage renal disease. Circulation. 2014;130:2005–11.View ArticlePubMedGoogle Scholar
- Ryden L, Ahnve S, Bell M, Hammar N, Ivert T, Sartipy U, et al. Acute kidney injury after coronary artery bypass grafting and long-term risk of myocardial infarction and death. Int J Cardiol. 2014;172:190–5.View ArticlePubMedGoogle Scholar
- Soto GJ, Frank AJ, Christiani DC, Gong MN. Body mass index and acute kidney injury in the acute respiratory distress syndrome. Crit Care Med. 2012;40:2601–8.PubMed CentralView ArticlePubMedGoogle Scholar
- Plataki M, Kashani K, Cabello-Garza J, Maldonado F, Kashyap R, Kor DJ, et al. Predictors of acute kidney injury in septic shock patients: an observational cohort study. Clin J Am Soc Nephrol. 2011;6:1744–51.View ArticlePubMedGoogle Scholar
- Hsu RK, Hsu CY. Proteinuria and reduced glomerular filtration rate as risk factors for acute kidney injury. Curr Opin Nephrol Hypertens. 2011;20:211–7.PubMed CentralView ArticlePubMedGoogle Scholar
- Grams ME, Astor BC, Bash LD, Matsushita K, Wang Y, Coresh J. Albuminuria and estimated glomerular filtration rate independently associate with acute kidney injury. J Am Soc Nephrol. 2010;21:1757–64.PubMed CentralView ArticlePubMedGoogle Scholar
- House AA. Cardio-renal syndrome type 4: epidemiology, pathophysiology and treatment. Semin Nephrol. 2012;32:40–8.View ArticlePubMedGoogle Scholar
- Shastri S, Sarnak MJ. Cardiovascular disease and CKD: core curriculum 2010. Am J Kidney Dis. 2010;56:399–417.View ArticlePubMedGoogle Scholar
- Tonelli M, Muntner P, Lloyd A, Manns BJ, Klarenbach S, Pannu N, et al. Risk of coronary events in people with chronic kidney disease compared with those with diabetes: a population-level cohort study. Lancet. 2012;380:807–14.View ArticlePubMedGoogle Scholar
- Washam JB, Herzog CA, Beitelshees AL, Cohen MG, Henry TD, Kapur NK, et al. Pharmacotherapy in chronic kidney disease patients presenting with acute coronary syndrome: a scientific statement from the American Heart Association. Circulation. 2015;131:1123–49.View ArticlePubMedGoogle Scholar
- Cruz DN, Gheorghiade M, Palazzuoli A, Ronco C, Bagshaw SM. Epidemiology and outcome of the cardio-renal syndrome. Heart Fail Rev. 2011;16:531–42.View ArticlePubMedGoogle Scholar
- Tonelli M, Wiebe N, Culleton B, House A, Rabbat C, Fok M, et al. Chronic kidney disease and mortality risk: a systematic review. J Am Soc Nephrol. 2006;17:2034–47.View ArticlePubMedGoogle Scholar
- Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med. 2004;351:1296–305.View ArticlePubMedGoogle Scholar
- Shroff GR, Frederick PD, Herzog CA. Renal failure and acute myocardial infarction: clinical characteristics in patients with advanced chronic kidney disease, on dialysis, and without chronic kidney disease. A collaborative project of the United States Renal Data System/National Institutes of Health and the National Registry of Myocardial Infarction. Am Heart J. 2012;163:399–406.PubMed CentralView ArticlePubMedGoogle Scholar
- Wright RS, Reeder GS, Herzog CA, Albright RC, Williams BA, Dvorak DL, et al. Acute myocardial infarction and renal dysfunction: a high-risk combination. Ann Intern Med. 2002;137:563–70.View ArticlePubMedGoogle Scholar
- Shlipak MG, Heidenreich PA, Noguchi H, Chertow GM, Browner WS, McClellan MB. Association of renal insufficiency with treatment and outcomes after myocardial infarction in elderly patients. Ann Intern Med. 2002;137:555–62.View ArticlePubMedGoogle Scholar
- Fox CS, Muntner P, Chen AY, Alexander KP, Roe MT, Cannon CP, et al. Use of evidence-based therapies in short-term outcomes of ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction in patients with chronic kidney disease: a report from the National Cardiovascular Data Acute Coronary Treatment and Intervention Outcomes Network registry. Circulation. 2010;121:357–65.PubMed CentralView ArticlePubMedGoogle Scholar
- Kusaba T, Humphreys BD. Controversies on the origin of proliferating epithelial cells after kidney injury. Pediatr Nephrol. 2014;29:673–9.PubMed CentralView ArticlePubMedGoogle Scholar
- Lin F, Moran A, Igarashi P. Intrarenal cells, not bone marrow-derived cells, are the major source for regeneration in postischemic kidney. J Clin Invest. 2005;115:1756–64.PubMed CentralView ArticlePubMedGoogle Scholar
- Duffield JS, Bonventre JV. Kidney tubular epithelium is restored without replacement with bone marrow-derived cells during repair after ischemic injury. Kidney Int. 2005;68:1956–61.PubMed CentralView ArticlePubMedGoogle Scholar
- Romagnani P, Lasagni L, Remuzzi G. Renal progenitors: an evolutionary conserved strategy for kidney regeneration. Nat Rev Nephrol. 2013;9:137–46.View ArticlePubMedGoogle Scholar
- Guyton AC. The surprising kidney-fluid mechanism for pressure control--its infinite gain! Hypertension. 1990;16:725–30.View ArticlePubMedGoogle Scholar
- Cannon PJ. The kidney in heart failure. N Engl J Med. 1977;296:26–32.View ArticlePubMedGoogle Scholar
- Stanton RC, Brenner BM. Role of the kidney in congestive heart failure. Acta Med Scand Suppl. 1986;707:21–5.PubMedGoogle Scholar
- WINTON FR. The influence of venous pressure on the isolated mammalian kidney. J Physiol. 1931;72:49–61.PubMed CentralView ArticlePubMedGoogle Scholar
- GOTTSCHALK CW, MYLLE M. Micropuncture study of pressures in proximal tubules and peritubular capillaries of the rat kidney and their relation to ureteral and renal venous pressures. Am J Physiol. 1956;185:430–9.PubMedGoogle Scholar
- Deen WM, Robertson CR, Brenner BM. A model of glomerular ultrafiltration in the rat. Am J Physiol. 1972;223:1178–83.PubMedGoogle Scholar
- 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;53:582–8.View ArticlePubMedGoogle Scholar
- Bongartz LG, Cramer MJ, Doevendans PA, Joles JA, Braam B. The severe cardiorenal syndrome: 'Guyton revisited'. Eur Heart J. 2005;26:11–7.View ArticlePubMedGoogle Scholar
- Sutton TA, Hato T, Mai E, Yoshimoto M, Kuehl S, Anderson M, et al. p53 is renoprotective after ischemic kidney injury by reducing inflammation. J Am Soc Nephrol. 2013;24:113–24.View ArticlePubMedGoogle Scholar
- Dagher PC, Mai EM, Hato T, Lee SY, Anderson MD, Karozos SC, et al. The p53 inhibitor pifithrin-alpha can stimulate fibrosis in a rat model of ischemic acute kidney injury. Am J Physiol Renal Physiol. 2012;302:F284–91.PubMed CentralView ArticlePubMedGoogle Scholar
- Jackson G, Gibbs CR, Davies MK, Lip GY. ABC of heart failure. Pathophysiology BMJ. 2000;320:167–70.PubMedGoogle Scholar
- Ronco C, Haapio M, House AA, Anavekar N, Bellomo R. Cardiorenal syndrome. J Am Coll Cardiol. 2008;52:1527–39.View ArticlePubMedGoogle Scholar
- Kingma JG, Simard D, Voisine P, Rouleau JR. Impact of chronic kidney disease on myocardial blood flow regulation in dogs. Nephron Experimental Nephrology. 2014;126:175–82.View ArticlePubMedGoogle Scholar
- Bidani AK, Griffin KA, Williamson G, Wang X, Loutzenhiser R. Protective importance of the myogenic response in the renal circulation. Hypertension. 2009;54:393–8.PubMed CentralView ArticlePubMedGoogle Scholar
- Kingma Jr JG, Vincent C, Rouleau JR, Kingma I. Influence of acute renal failure on coronary vasoregulation in dogs. J Am Soc Nephrol. 2006;17:1316–24.View ArticlePubMedGoogle Scholar
- Wang Y, Bao X. Effects of uric acid on endothelial dysfunction in early chronic kidney disease and its mechanisms. Eur J Med Res. 2013;18:26.PubMed CentralView ArticlePubMedGoogle Scholar
- Klassen PS, Lowrie EG, Reddan DN, DeLong ER, Coladonato JA, Szczech LA, et al. Association between pulse pressure and mortality in patients undergoing maintenance hemodialysis. J Am Med Assoc. 2002;287:1548–55.View ArticleGoogle Scholar
- Agarwal R. Blood pressure components and the risk for end-stage renal disease and death in chronic kidney disease. Clin J Am Soc Nephrol. 2009;4:830–7.PubMed CentralView ArticlePubMedGoogle Scholar
- Muntner P, He J, Hamm L, Loria C, Whelton PK. Renal insufficiency and subsequent death resulting from cardiovascular disease in the United States. J Am Soc Nephrol. 2002;13:745–53.PubMedGoogle Scholar
- Ejaz AA, Mohandas R. Are diuretics harmful in the management of acute kidney injury? Curr Opin Nephrol Hypertens. 2014;23:155–60.View ArticlePubMedGoogle Scholar
- Ho KM, Sheridan DJ. Meta-analysis of frusemide to prevent or treat acute renal failure. BMJ. 2006;333:420.PubMed CentralView ArticlePubMedGoogle Scholar
- Bagshaw SM, Delaney A, Haase M, Ghali WA, Bellomo R. Loop diuretics in the management of acute renal failure: a systematic review and meta-analysis. Crit Care Resusc. 2007;9:60–8.PubMedGoogle Scholar
- Joannidis M, Druml W, Forni LG, Groeneveld AB, Honore P, Oudemans-van Straaten HM, et al. Prevention of acute kidney injury and protection of renal function in the intensive care unit. Expert opinion of the Working Group for Nephrology, ESICM. Intensive Care Med. 2010;36:392–411.View ArticlePubMedGoogle Scholar
- KDIGO. Clinical practice guideline for acute kidney injury. Kidney Int. 2012;2:1–138.View ArticleGoogle Scholar
- Kovesdy CP, Trivedi BK, Kalantar-Zadeh K, Anderson JE. Association of low blood pressure with increased mortality in patients with moderate to severe chronic kidney disease. Nephrol Dial Transplant. 2006;21:1257–62.View ArticlePubMedGoogle Scholar
- Sim JJ, Shi J, Kovesdy CP, Kalantar-Zadeh K, Jacobsen SJ. Impact of achieved blood pressures on mortality risk and end-stage renal disease among a large, diverse hypertension population. J Am Coll Cardiol. 2014;64:588–97.PubMed CentralView ArticlePubMedGoogle Scholar
- Kim CS. Pharmacologic Management of the Cardio-renal Syndrome. Electrolyte Blood Press. 2013;11:17–23.PubMed CentralView ArticlePubMedGoogle Scholar
- Klein L, Massie BM, Leimberger JD, O'connor CM, Pina IL, Adams Jr KF, et al. Admission or changes in renal function during hospitalization for worsening heart failure predict postdischarge survival: results from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF). Circ Heart Fail. 2008;1:25–33.View ArticlePubMedGoogle Scholar
- Lauschke A, Teichgraber UK, Frei U, Eckardt KU. 'Low-dose' dopamine worsens renal perfusion in patients with acute renal failure. Kidney Int. 2006;69:1669–74.View ArticlePubMedGoogle Scholar
- 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;16:922–30.View ArticlePubMedGoogle Scholar
- Mebazaa A, Nieminen MS, Packer M, Cohen-Solal A, Kleber FX, Pocock SJ, et al. Levosimendan vs dobutamine for patients with acute decompensated heart failure: the SURVIVE Randomized Trial. J Am Med Assoc. 2007;297:1883–91.View ArticleGoogle Scholar
- 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. J A M A. 2007;297:1319–31.View ArticlePubMedGoogle Scholar
- Voors AA, Dittrich HC, Massie BM, Delucca P, Mansoor GA, Metra M, 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 Adenosine A1 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. 2011;57:1899–907.View ArticlePubMedGoogle Scholar
- Gottlieb SS, Givertz MM, Metra M, Gergich K, Bird S, Jones-Burton C, et al. The effects of adenosine A(1) receptor antagonism in patients with acute decompensated heart failure and worsening renal function: the REACH UP study. J Card Fail. 2010;16:714–9.View ArticlePubMedGoogle Scholar
- Ljungman S, Kjekshus J, Swedberg K. Renal function in severe congestive heart failure during treatment with enalapril (the Cooperative North Scandinavian Enalapril Survival Study [CONSENSUS] Trial). Am J Cardiol. 1992;70:479–87.View ArticlePubMedGoogle Scholar
- Pitt B, Zannad F, Remme WJ, Cody R, Castaigne A, Perez A, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators. N Engl J Med. 1999;341:709–17.View ArticlePubMedGoogle Scholar
- Pitt B, Remme W, Zannad F, Neaton J, Martinez F, Roniker B, et al. Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction. N Engl J Med. 2003;348:1309–21.View ArticlePubMedGoogle Scholar
- Yagi S, Aihara K, Ikeda Y, Akaike M, Sata M, Matsumoto T. Effects of statins on cardiorenal syndrome. Int J Vasc Med. 2012;2012:162545.PubMed CentralPubMedGoogle Scholar
- Fujii M, Inoguchi T, Maeda Y, Sasaki S, Sawada F, Saito R, et al. Pitavastatin ameliorates albuminuria and renal mesangial expansion by downregulating NOX4 in db/db mice. Kidney Int. 2007;72:473–80.View ArticlePubMedGoogle Scholar
- Liang XM, Otani H, Zhou Q, Tone Y, Fujii R, Mune M, et al. Renal protective effects of pitavastatin on spontaneously hypercholesterolaemic Imai Rats. Nephrol Dial Transplant. 2007;22:2156–64.View ArticlePubMedGoogle Scholar
- Strippoli GF, Navaneethan SD, Johnson DW, Perkovic V, Pellegrini F, Nicolucci A, et al. Effects of statins in patients with chronic kidney disease: meta-analysis and meta-regression of randomised controlled trials. BMJ. 2008;336:645–51.PubMed CentralView ArticlePubMedGoogle Scholar
- Atthobari J, Brantsma AH, Gansevoort RT, Visser ST, Asselbergs FW, Van Gilst WH, et al. The effect of statins on urinary albumin excretion and glomerular filtration rate: results from both a randomized clinical trial and an observational cohort study. Nephrol Dial Transplant. 2006;21:3106–14.View ArticlePubMedGoogle Scholar
- Ruggenenti P, Perna A, Tonelli M, Loriga G, Motterlini N, Rubis N, et al. Effects of add-on fluvastatin therapy in patients with chronic proteinuric nephropathy on dual renin-angiotensin system blockade: the ESPLANADE trial. Clin J Am Soc Nephrol. 2010;5:1928–38.PubMed CentralView ArticlePubMedGoogle Scholar
- DiBona GF, Kopp UC. Neural control of renal function. Physiol Rev. 1997;77:75–197.PubMedGoogle Scholar
- Mahfoud F, Schlaich M, Kindermann I, Ukena C, Cremers B, Brandt MC, et al. Effect of renal sympathetic denervation on glucose metabolism in patients with resistant hypertension: a pilot study. Circulation. 2011;123:1940–6.View ArticlePubMedGoogle Scholar
- Veelken R, Vogel EM, Hilgers K, Amann K, Hartner A, Sass G, et al. Autonomic renal denervation ameliorates experimental glomerulonephritis. J Am Soc Nephrol. 2008;19:1371–8.PubMed CentralView ArticlePubMedGoogle Scholar
- Simplicity HTN-1 Investigators. Catheter-based renal sympathetic denervation for resistant hypertension: durability of blood pressure reduction out to 24 months. Hypertension. 2011;57:911–7.View ArticleGoogle Scholar
- Esler MD, Krum H, Schlaich M, Schmieder RE, Bohm M, Sobotka PA. Renal sympathetic denervation for treatment of drug-resistant hypertension: one-year results from the Symplicity HTN-2 randomized, controlled trial. Circulation. 2012;126:2976–82.View ArticlePubMedGoogle Scholar
- Veelken R, Schmieder RE. Renal denervation--implications for chronic kidney disease. Nat Rev Nephrol. 2014;10:305–13.View ArticlePubMedGoogle Scholar
- Bakris GL, Townsend RR, Liu M, Cohen SA, D'Agostino R, Flack JM, et al. Impact of renal denervation on 24-hour ambulatory blood pressure: results from SYMPLICITY HTN-3. J Am Coll Cardiol. 2014;64:1071–8.View ArticlePubMedGoogle Scholar
- Kharbanda RK, Nielsen TT, Redington AN. Translation of remote ischaemic preconditioning into clinical practice. Lancet. 2009;374:1557–65.View ArticlePubMedGoogle Scholar
- Przyklenk K, Bauer B, Ovize M, Kloner RA, Whittaker P. Regional ischemic preconditioning protects remote virgin myocardium from subsequent coronary occlusion. Circulation. 1993;87:893–9.View ArticlePubMedGoogle Scholar
- Vinten-Johansen J, Shi W. Perconditioning and postconditioning: current knowledge, knowledge gaps, barriers to adoption, and future directions. J Cardiovasc Pharmacol Ther. 2011;16:260–6.View ArticlePubMedGoogle Scholar
- Kingma JG. Conditioning strategies limit cellular injury? World Journal of Cardiovascular Diseases. 2014;4:539–47.View ArticleGoogle Scholar
- Kingma JG, Simard D, Voisine P, Rouleau JR. Role of the autonomic nervous system in cardioprotection by remote preconditioning in isoflurane-anaesthetized dogs. Cardiovasc Res. 2011;89:384–91.View ArticlePubMedGoogle Scholar
- Dikow R, Kihm LP, Zeier M, Kapitza J, Tornig J, Amann K, et al. Increased infarct size in uremic rats: reduced ischemia tolerance? J Am Soc Nephrol. 2004;15:1530–6.View ArticlePubMedGoogle Scholar
- Byrne CJ, McCafferty K, Kieswich J, Harwood S, Andrikopoulos P, Raftery M, et al. Ischemic conditioning protects the uremic heart in a rodent model of myocardial infarction. Circulation. 2012;125:1256–65.View ArticlePubMedGoogle Scholar
- Gardner DS, Welham SJ, Dunford LJ, McCulloch TA, Hodi Z, Sleeman P, et al. Remote conditioning or erythropoietin before surgery primes kidneys to clear ischemia-reperfusion-damaged cells: a renoprotective mechanism? Am J Physiol Renal Physiol. 2014;306:F873–84.PubMed CentralView ArticlePubMedGoogle Scholar
- Igarashi G, Iino K, Watanabe H, Ito H. Remote ischemic pre-conditioning alleviates contrast-induced acute kidney injury in patients with moderate chronic kidney disease. Circ J. 2013;77:3037–44.View ArticlePubMedGoogle Scholar
- Soendergaard P, Krogstrup NV, Secher NG, Ravlo K, Keller AK, Toennesen E, et al. Improved GFR and renal plasma perfusion following remote ischaemic conditioning in a porcine kidney transplantation model. Transpl Int. 2012;25:1002–12.View ArticlePubMedGoogle Scholar
- Crowley LE, McIntyre CW. Remote ischaemic conditioning-therapeutic opportunities in renal medicine. Nat Rev Nephrol. 2013;9:739–46.View ArticlePubMedGoogle Scholar
- Er F, Nia AM, Dopp H, Hellmich M, Dahlem KM, Caglayan E, et al. Ischemic preconditioning for prevention of contrast medium-induced nephropathy: randomized pilot RenPro Trial (Renal Protection Trial). Circulation. 2012;126:296–303.View ArticlePubMedGoogle Scholar