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      Cardio-renal syndromes: report from the consensus conference of the Acute Dialysis Quality Initiative

      1 , 2 , * , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 1 , 1 , 2 , 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 11 , 22 , 23 , 1 , 24 , 25 , 26 , 27 , for the Acute Dialysis Quality Initiative (ADQI) consensus group

      European Heart Journal

      Oxford University Press

      Cardio-renal syndromes, Acute heart failure, Acute kidney injury, Chronic kidney disease, Worsening renal function, Chronic heart disease, Chronic heart failure

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          Abstract

          A consensus conference on cardio-renal syndromes (CRS) was held in Venice Italy, in September 2008 under the auspices of the Acute Dialysis Quality Initiative (ADQI). The following topics were matter of discussion after a systematic literature review and the appraisal of the best available evidence: definition/classification system; epidemiology; diagnostic criteria and biomarkers; prevention/protection strategies; management and therapy. 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): acute worsening of heart function (AHF–ACS) leading to kidney injury and/or dysfunction. Chronic cardio-renal syndrome (type 2): chronic abnormalities in heart function (CHF-CHD) leading to kidney injury and/or dysfunction. Acute reno-cardiac syndrome (type 3): acute worsening of kidney function (AKI) leading to heart injury and/or dysfunction. Chronic reno-cardiac syndrome (type 4): chronic kidney disease leading to heart injury, disease, and/or dysfunction. Secondary CRS (type 5): systemic conditions leading to simultaneous injury and/or dysfunction of heart and kidney. Consensus statements concerning epidemiology, diagnosis, prevention, and management strategies are discussed in the paper for each of the syndromes.

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          Chronic kidney disease and mortality risk: a systematic review.

          Current guidelines identify people with chronic kidney disease (CKD) as being at high risk for cardiovascular and all-cause mortality. Because as many as 19 million Americans may have CKD, a comprehensive summary of this risk would be potentially useful for planning public health policy. A systematic review of the association between non-dialysis-dependent CKD and the risk for all-cause and cardiovascular mortality was conducted. Patient- and study-related characteristics that influenced the magnitude of these associations also were investigated. MEDLINE and EMBASE databases were searched, and reference lists through December 2004 were consulted. Authors of 10 primary studies provided additional data. Cohort studies or cohort analyses of randomized, controlled trials that compared mortality between those with and without chronically reduced kidney function were included. Studies were excluded from review when participants were followed for < 1 yr or had ESRD. Two reviewers independently extracted data on study setting, quality, participant and renal function characteristics, and outcomes. Thirty-nine studies that followed a total of 1,371,990 participants were reviewed. The unadjusted relative risk for mortality in participants with reduced kidney function compared with those without ranged from 0.94 to 5.0 and was significantly more than 1.0 in 93% of cohorts. Among the 16 studies that provided suitable data, the absolute risk for death increased exponentially with decreasing renal function. Fourteen cohorts described the risk for mortality from reduced kidney function, after adjustment for other established risk factors. Although adjusted relative hazards were consistently lower than unadjusted relative risks (median reduction 17%), they remained significantly more than 1.0 in 71% of cohorts. This review supports current guidelines that identify individuals with CKD as being at high risk for cardiovascular mortality. Determining which interventions best offset this risk remains a health priority.
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            Cardiorenal syndrome.

            The term cardiorenal syndrome (CRS) increasingly has been used without a consistent or well-accepted definition. To include the vast array of interrelated derangements, and to stress the bidirectional nature of heart-kidney interactions, we present a new classification of the CRS with 5 subtypes that reflect the pathophysiology, the time-frame, and the nature of concomitant cardiac and renal dysfunction. CRS can be generally defined as a pathophysiologic disorder of the heart and kidneys whereby acute or chronic dysfunction of 1 organ may induce acute or chronic dysfunction of the other. Type 1 CRS reflects an abrupt worsening of cardiac function (e.g., acute cardiogenic shock or decompensated congestive heart failure) leading to acute kidney injury. Type 2 CRS comprises chronic abnormalities in cardiac function (e.g., chronic congestive heart failure) causing progressive chronic kidney disease. Type 3 CRS consists of an abrupt worsening of renal function (e.g., acute kidney ischemia or glomerulonephritis) causing acute cardiac dysfunction (e.g., heart failure, arrhythmia, ischemia). Type 4 CRS describes a state of chronic kidney disease (e.g., chronic glomerular disease) contributing to decreased cardiac function, cardiac hypertrophy, and/or increased risk of adverse cardiovascular events. Type 5 CRS reflects a systemic condition (e.g., sepsis) causing both cardiac and renal dysfunction. Biomarkers can contribute to an early diagnosis of CRS and to a timely therapeutic intervention. The use of this classification can help physicians characterize groups of patients, provides the rationale for specific management strategies, and allows the design of future clinical trials with more accurate selection and stratification of the population under investigation.
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              ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2008: the Task Force for the diagnosis and treatment of acute and chronic heart failure 2008 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association of the ESC (HFA) and endorsed by the European Society of Intensive Care Medicine (ESICM).

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                Author and article information

                Journal
                Eur Heart J
                eurheartj
                ehj
                European Heart Journal
                Oxford University Press
                0195-668X
                1522-9645
                March 2010
                25 December 2009
                25 December 2009
                : 31
                : 6
                : 703-711
                Affiliations
                [1 ]Department of Nephrology, San Bortolo Hospital , Viale Rodolfi 37, Vicenza 36100, Italy
                [2 ]IRRIV, International Renal Research Institute of Vicenza, Vicenza , Italy
                [3 ]Division of Cardiology, Department of Medicine, Nutrition and Preventive Medicine, William Beaumont Hospital , Royal Oak, MI, USA
                [4 ]Department of Cardiology, Applied Cachexia Research , Charité, Campus Virchow-Klinikum, Berlin, Germany
                [5 ]Centre for Clinical and Basic Research, IRCCS San Raffaele , Rome, Italy
                [6 ]Department of Cardiology, VA Medical Centre , Minneapolis, MN, USA
                [7 ]Department of Cardiology, St Spirito Hospital , Rome, Italy
                [8 ]Division of Critical Care Medicine, University of Alberta Hospital , Edmonton, Canada
                [9 ]Department of Intensive Care, Austin Hospital , Melbourne, Australia
                [10 ]Department of Nephrology, University of Colorado Health Sciences Center , Denver, CO, USA
                [11 ]Department of Cardiology, University of Padova , Padova, Italy
                [12 ]UCL Center for Nephrology, Royal Free and University College Medical School , London, UK
                [13 ]Division of Nephrology, Helsinki University Central Hospital , Helsinki, Finland
                [14 ]Trial Coordination Center, Department of Cardiology and Epidemiology, University Medical Center Groningen , Hanzeplein, The Netherlands
                [15 ]Division of Nephrology, London Health Sciences Centre, University Hospital , London, Ont, Canada
                [16 ]Department of Surgery, The George Washington University , Washington, DC, USA
                [17 ]Department of Medicine and Cardiology, San Diego VA Medical Center and University of California , San Diego, CA, USA
                [18 ]Department of Cardiology, Mayo Clinic , Rochester, MN, USA
                [19 ]Department of Nuclear Medicine, San Bortolo Hospital , Vicenza, Italy
                [20 ]Department of Anesthesiology and Critical Care Medicine, Hôpital Lariboisière. U 942 Inserm; University Paris 7 , Paris Diderot, France
                [21 ]Department of Internal Medicine, University of Siena, Le Scotte Hospital , Siena, Italy
                [22 ]Department of Anesthesiology, Duke University Medical Center , Durham, NC, USA
                [23 ]Department of Critical Care, University of Maryland , College Park, MD, USA
                [24 ]Division of Nephrology, Mediciti Hospitals , Hyderabad, India
                [25 ]Department of Internal Medicine, San Bortolo Hospital , Vicenza, Italy
                [26 ]Department of Intensive Care, San Bortolo Hospital , Vicenza, Italy
                [27 ]Cardiac Department, Faculty of Public Health, Medical University, Military Hospital , Wroclaw, Poland
                Author notes
                [* ]Corresponding author. Email: cronco@ 123456goldnet.it
                Article
                ehp507
                10.1093/eurheartj/ehp507
                2838681
                20037146
                Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2009. For permissions please email: journals.permissions@oxfordjournals.org

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                Categories
                Clinical Research
                Heart failure/cardiomyopathy

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