Cardiorenal syndrome (CRS) type 1 is characterized as the development of .. C. Ronco, P.A. McCullough, S.D. Anker, et al., Acute Dialysis Quality Initiative. Cardiorenal Syndrome. Claudio Ronco . based on primum movens of disease ( cardiac or renal); both cardiorenal and renocardiac CRS are. Classification of Cardio-Renal Syndrome. Ronco C, DiLullo L. Heart Failure Clin 10 () Ronco C et al. J ACC ;52;

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The following topics were matter of discussion after a syjdrome literature rohco and the appraisal of the best available evidence: The umbrella term CRS was used to identify a disorder of the heart and kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction in the other organ.

Different syndromes were identified and classified into five subtypes. Acute CRS type 1: Chronic carddiorenal syndrome type 2: Acute reno-cardiac syndrome type 3: Chronic reno-cardiac syndrome type 4: Secondary CRS type 5: Consensus statements concerning epidemiology, diagnosis, prevention, and management strategies are discussed in the paper for each of the syndromes.

Cardiac and renal diseases are common and frequently coexist syndroke significantly increase mortality, morbidity, and the complexity and cost of care. Thus, there is limited appreciation of epidemiology and standardized diagnostic criteria.

Moreover, prevention and treatment is fragmented, single organ centred, and not multidisciplinary catdiorenal approach. As a result, timing and quality of care may suffer. It involved opinion leaders and experts in nephrology, critical care, cardiac surgery, and dardiorenal.

In this manuscript, we present the findings of this consensus conference. The ADQI process was applied. Before the conference, topics were selected and work groups assembled. Groups identified the key questions and conducted a systematic literature search. During the conference, work groups assembled in breakout sessions, as well as plenary sessions where their findings were presented, debated, and refined.

Key questions were identified by the group and subgroups deliberated on these questions, bringing forth recommendations to the group as a whole. Deliberations followed 3 days of discussion among 32 attendees. Summary statements were then developed by the entire group as reported here.

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The Steering Committee assembled an expert panel, which was divided into five smaller working groups: Cardirenal unanimously agreed that a consensus definition was needed to highlight the coexistence of cardiac and renal disorders and to identify the time course of heart—kidney interaction and the primacy of the organ leading to the syndrome.

The goal of this definition would be to roco epidemiological studies, identify target populations for intervention, develop diagnostic tools, prevent and manage different syndromes. We chose a broad term, using the plural cardio-renal syndromes, CRSto indicate the presence of multiple syndromes.

We chose subtypes to recognize primary organ dysfunction cardiac vs. We added an additional syndrone to capture systemic conditions affecting both organs simultaneously. We chose definitions to include accepted criteria published by national and international societies. We cardiprenal definitions from the literature and used a specific publication 4 as template.

Pathophysiology and definitions of the five subtypes of cardio-renal syndrome modified by Ronco et al. We chose the term CRS to indicate the bidirectional nature of the various syndromes and to recognize that this term was already established in the medical lexicon, despite lack of formal definition.

Cardiorenal syndrome.

These patients experience higher mortality and morbidity, and increased length of hospitalization. Chronic abnormalities in heart function leading to kidney injury or dysfunction. This subtype refers to a more chronic state of kidney disease complicating chronic heart disease. This subtype refers to abnormalities in cardiac function secondary to AKI. The pathophysiological mechanisms likely go beyond simple volume overload and the recent consensus definition of AKI 12 may help to investigate this syndrome further.


Syndroje subtype syndromw to disease or dysfunction of the heart occurring secondary to CKD.

There is a graded and independent association between the severity of CKD and adverse cardiac outcomes. Examples include sepsis, systemic lupus erythematosus, diabetes mellitus, amyloidosis, or other chronic inflammatory conditions. The ADQI working group recognized that many patients may populate or move between subtypes during the course of their disease. The group discussed and considered further sub-classification, to include situations of transient or reversible dysfunction, slowly or acutely progressive vs.

In cardio-renal syndromes, there are two important aspects: Another important aspect is the time frame in which the derangements occur chronic or acute. In all cases, there are moments in which prevention is possible, in others mitigation of the insult is potentially feasible, in others, therapeutic strategies must be implemented.

At different times, a crucial role is played by imaging techniques and biomarkers enabling the clinician to make an early diagnosis, establish illness severity, and to potentially predict outcomes. This flowchart describes a series of conditions indicating that patients may move from one type to another of cardio-renal syndromes.

Cardio-renal syndromes are characterized by significant heart—kidney interactions that share similarities in pathophysiology. However, they are also likely to have important discriminating features, in terms of predisposing or precipitating events, natural history, and outcomes. A description of the epidemiology of heart—kidney interaction, stratified by the CRS subtypes, is a critical initial step towards understanding the overall burden of disease for each CRS subtype and vital in determining the presence of gaps in knowledge and helping design future trials.

A large body of literature has examined AKI due to worsening heart function. This broad range is largely attributable to variations in the definitions of WRF, the observed time-at-risk and the population under study. This finding was apparent across the spectrum of systemic blood pressure, pulmonary capillary wedge pressure, cardiac index, and estimated glomerular filtration rates.

Chronic heart disease and CKD frequently co-exist, and often the clinical scenario does not permit to distinguish which disease came first.

Large database studies do not distinguish between type 2 and type 4 CRS. Nevertheless, between 45 and In selected circumstances, long-standing CHD results in adaptive alterations in kidney perfusion and neurohormonal activation. Kidney dysfunction was observed even among CHD patients with simple anatomical cardiac defects.

A further challenge in describing the epidemiology of type 2 CRS is that patients may also transition between type 1 and type 2 CRS at various time points.

Defining the epidemiology of acute reno-cardiac syndrome type 3 is challenging for several reasons: Accordingly, incidence estimates and clinical outcomes of acute cardiac dysfunction secondary to AKI are largely context and disease-specific. Toxaemia, fluid and sodium retention, humoral mediators, and electrolyte derangements may all contribute to acute dysfunction of the heart.

This discrimination may have relevance as these two presentations may be characterized by important differences in epidemiology, risk factors, associated outcomes, and need for differing therapeutic interventions. Several observational studies have evaluated the cardiovascular event rates and outcomes in selected CKD populations. Several observational studies have found graded increases in the prevalence of CVD and heart failure HFalong with higher risk of subsequent cardiac events associated with degree of decline in kidney function.

There are limited data on the epidemiology of secondary CRS type 5 due to the large number of potential contributing acute and chronic systemic conditions.

We recognize that several chronic systemic illnesses i. Importantly, in this context, there is currently an incomplete understanding of the pathophysiological mechanisms of secondary heart—kidney interactions.

A prototypical condition that may lead to CRS type 5 is sepsis. The consensus group deliberated on the role of biomarkers in the diagnosis of the different types of the syndrome.

The intention was to integrate biomarkers into the diagnosis of the various CRS, especially those that deal with AKI on top of acute cardiac disease. If biomarkers are to be clinically useful in these settings, physicians must be able to answer the following questions: Moreover, they have shown prognostic roncoo in patients with various stages of renal insufficiency, 7576 demonstrating potential applications in CRS types 2 and 4.


Although many previous synrdome support the usefulness of BNP in the diagnosis and management of HF patients, 7778 the relationship between BNP, renal function, and the severity of HF is less clear.

Neutrophil gelatinase-associated lipocalin NGAL seems to be one of the earliest kidney markers of ischaemic or nephrotoxic injury in animal models and is detected in the blood and urine of humans soon after AKI. Cystatin C appears to be a better predictor of glomerular function than serum creatinine in patients with CKD. Kidney injury molecule-1 KIM-1 is a protein detectable in the urine after ischaemic or nephrotoxic insults to proximal tubular cells.

Interleukin IL is a pro-inflammatory cytokine detected in the urine after acute ischaemic proximal tubular damage. Of the biomarkers presented above, NGAL urine and plasma and Cystatin C are most likely to be integrated into clinical practice in the near future.

Clinical trials will be needed to see if earlier identification of AKI and the use of specific treatment algorithms based on these markers will improve prognosis. There is a general agreement that bioimpedance vector analysis BIVA may contribute to a better definition of the patient’s hydration status.

In this way, patients will be kept within the narrow window of adequate hydration preventing worsening of both kidney and heart function. Imaging techniques have an additional role with respect to the laboratory biomarkers in CRS.

They may enhance, extend, and refine our ability to quantify renal damage and function. In patients affected by suspected CRS, it is prudent to avoid the use of iodinated contrast media if not strictly necessary. Also in the future, non-invasive imaging techniques should be refined to quantify renal blood flow. Such data can then be correlated with cardiac and renal biomarkers and most importantly guide ongoing therapy designed to optimize renal blood flow and ultimately preserve kidney function.

As for type 1 CRS, venous congestion and high CVP seem to be associated with impaired renal function and independently related to all-cause mortality in a broad spectrum of patients with cardiovascular disease. The rationale for the prevention of CRS is based on the concept that once the syndrome begins it is difficult to interrupt, not completely reversible in all cases, and associated with serious adverse outcomes.

We approached prevention using a proposed classification system. These call for blood pressure control, use of drugs that block the renin—angiotensin—aldosterone system, beta-adrenergic blockers BBcoronary artery disease risk factor modification, and compliance with dietary and drug treatments. In this setting, therapies that improve the natural history of chronic HF include angiotensin converting enzyme inhibitors ACE-Iangiotensin receptor blockers ARBBB, aldosterone receptor blockers, combination of nitrates and hydralazine, and cardiac re-synchronization therapy.

The clinical problem in many cases is sodium and water retention. Avoidance of hypervolaemia should help prevent cardiac decompensation.

In addition, uremic changes, rohco, and mediators of inflammation can have adverse cardiac consequences. Contrast-induced AKI in most cases is asymptomaticand unlikely to cause cardiac dysfunction. Type 4 CRS is a common syndrome since it involves the syyndrome of CKD, often due to diabetes mellitus and hypertension, with accelerated calcific atherosclerosis, progressive LVH, and the development of diastolic and systolic dysfunction.

A core concept is that treatment of the primary illness diabetes mellitus, amyloidosis, sepsis, rhabdomyolysis, haemorrhagic shock, etc. Both abnormal renal function and also a deterioration early in the course of treatment of ADHF increase mortality.

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