Drugs involved in the treatment of Cardio renal syndrome (CRS) and types

Journal of Kidney Treatment and Diagnosis consists of the latest findings related to pathogenesis and treatment of kidney disease, hypertension, acid-base and electrolyte disorders, dialysis therapies, and kidney transplantation.
Cardio renal syndrome (CRS) is an umbrella term used in the medical field that defines disorders of the heart and kidneys whereby “acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other”. The heart and the kidneys are involved in maintaining hemodynamic stability and organ perfusion through an intricate network. This definition has since been challenged repeatedly but there still remains little consensus over a universally accepted definition for CRS. At a consensus conference of the Acute Dialysis Quality Initiative (ADQI), the CRS was classified into five subtypes primarily based upon the organ that initiated the insult as well as the acuity of disease
Classification
Ronco et al. first proposed a five-part classification system for CRS in 2008 which was also accepted at ADQI consensus conference in 2010. These include:
Type |
Inciting event |
Secondary disturbance |
Example |
Type 1 (acute CRS) |
Abrupt worsening of heart function |
kidney injury |
acute cardiogenic shock or acute decompensation of chronic heart failure |
Type 2 (chronic CRS) |
Chronic abnormalities in heart function |
progressive chronic kidney disease |
chronic heart failure |
Type 3 (acute renocardiac syndrome) |
Abrupt worsening of kidney function |
acute cardiac disorder (e.g. heart failure, abnormal heart rhythm, or pulmonary edema) |
acute kidney failure or glomerulonephritis |
Type 4 (chronic renocardiac syndrome) |
Chronic kidney disease |
decreased cardiac function, cardiac hypertrophy and/or increased risk of adverse cardiovascular events |
chronic glomerular disease |
Type 5 (secondary CRS) |
Systemic condition |
both heart and kidney dysfunction |
diabetes mellitus, sepsis, lupus |
Medical management of patients with CRS is often challenging as focus on treatment of one organ may have worsening outcome on the other. It is known that many of the medications used to treat HF may worsen kidney function. In addition, many trials on HF excluded patients with advanced kidney dysfunction. Therefore, our understanding of CRS management is still limited to this date.
Diuretics
Used in the treatment of heart failure and CRS patients, however must be carefully dosed to prevent kidney injury. Diuretic resistance is frequently a challenge for physicians to overcome which they may tackle by changing the dosage, frequency, or adding a second drug.
ACEI, ARB, renin inhibitors, aldosterone inhibitors
The use of ACE inhibitors have long term protective effect on kidney and heart tissue. However, they should be used with caution in patients with CRS and kidney failure. Although patients with kidney failure may experience slight deterioration of kidney function in the short term, the use of ACE inhibitors is shown to have prognostic benefit over the long term. Two studies have suggested that the use of ACEI alongside statins might be an effective regimen to prevent a substantial number of CRS cases in high risk patients and improve survival and quality of life in these people. There are data suggesting combined use of statin and an ACEI improves clinical outcome more than a statin alone and considerably more than ACE inhibitor alone.
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With Regards,
John Matthews
Managing Editor
Journal of Kidney Treatment and Diagnosis
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