Acute Cardiorenal Syndrome in Heart Failure: from Dogmas to Advances
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HEART FAILURE (HJ EISEN, SECTION EDITOR)
Acute Cardiorenal Syndrome in Heart Failure: from Dogmas to Advances W. H. Wilson Tang 1
&
Alan Kiang 1
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review This review aims to summarize our current understanding and management strategies of acute cardiorenal syndrome (CRS). Recent Findings The definition of acute CRS remains debated, in part due to the lack of reliable insights into salt and water handling of the kidneys beyond impairment in glomerular filtration. Protocolized use of loop diuretics to ensure adequate delivery to their target of action, as well as segmental tubular blockade with adjunctive use of thiazide diuretics, acetazolamide, amiloride, or sodium-glucose transporter 2 (SGLT2) inhibitors, may result in more effective natriuresis in patients with acute CRS who exhibit diuretic resistance. Other strategies, such as modulating renal sodium avidity with the use of hypertonic saline, reduction of intra-abdominal pressure, or device-based salt and volume removal, are promising and warrant further investigation. Summary Acute CRS remains a significant contributor of morbidity and mortality for the acute heart failure population. New strategies have challenged current dogmas in our understanding of its pathophysiology, which may lead to potential new treatment approaches. Keywords Cardiorenal syndrome . Worsening renal function . Diuretic resistance . Heart failure . SGLT2 inhibitors . Hypertonic saline
Introduction The concept of “cardiorenal” disease was first described in 1914 by Dr. Alfred Stengel [1]. He proposed the term “cardiorenal” that referred to “cases of combined cardiovascular and renal disease without such manifest predominance of either as to justify a prompt determination of the one element as primary and important and the other as secondary and unimportant.” Dr. Stengel presented an empiric framework categorizing these patients into three groups that would each require different treatment strategies: (1) those with primary This article is part of the Topical Collection on Heart Failure * W. H. Wilson Tang [email protected] Alan Kiang [email protected] 1
Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH 44195, USA
heart failure (HF) leading to secondary renal failure, (2) atherosclerotic vascular disease leading to both secondary HF and renal failure, and (3) primary renal failure leading to secondary HF [1]. By proposing this framework, Stengel’s goal was to help clinicians better identify and treat the primary insult in any given patient presenting with “cardiorenal” disease. It is therefore important to appreciate that different and complex pathophysiologic processes leading to the disruption of the intricate interdependence of the heart and the kidneys have long been recognized for over a century, prior to any effective treatment strategies or diagnostic tests. Today, the term “cardiorenal syndrome” (CRS) r
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