Cardiorenal SyndromeClassification and Treatment

Jenny Chan PharmD Candidate ℅ 2015HMC Cardiology 08/26/14

What is a Syndrome? Definition: A group of symptoms that consistently occur together or a condition characterized by a set of associated symptoms.

Cardiorenal Syndrome (CRS)Type 1: Acute CRSType 2: Chronic CRSType 3: Acute Renocardiac SyndromeType 4: Chronic Renocardiac SyndromeType 5: Secondary CRS

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

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

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

Diagnostic Markers of AKI● Early diagnosis is desired● Neutrophil gelatinase-associated lipocalin

(NGAL)● Cystatin C

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

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.

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.

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

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.

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.

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.

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.

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.

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

THANK YOU!Matt and Greg