Chronic kidney disease and worsening renal function in acute heart failure: different phenotypes with similar prognostic impact?

Abstract

Nearly a third of patients with acute heart failure experience concomitant renal dysfunction. This condition is often associated with increased costs of care, length of hospitalisation and high mortality. Although the clinical impact of chronic kidney disease (CKD) has been well established, the exact clinical significance of worsening renal function (WRF) during the acute and post-hospitalisation phases is not completely understood. Therefore, it is still unclear which of the common laboratory markers are able to identify WRF at an early stage. Recent studies comparing CKD with WRF showed contradictory results; this could depend on a different WRF definition, clinical characteristics, haemodynamic disorders and the presence of prior renal dysfunction in the population enrolled. The current definition of acute cardiorenal syndrome focuses on both the heart and kidney but it lacks precise laboratory marker cut-offs and a specific diagnostic approach. WRF and CKD could represent different pathophysiological mechanisms in the setting of acute heart failure; the traditional view includes reduced cardiac output with systemic and renal vasoconstriction. Nevertheless, it has become a mixed model that encompasses both forward and backward haemodynamic dysfunction. Increased central venous pressure, renal congestion with tubular obliteration, tubulo-glomerular feedback and increased abdominal pressure are all potential additional contributors. The impact of WRF on patients who experience preserved renal function and individuals affected with CKD is currently unknown. Therefore it is extremely important to understand the origins, the clinical significance and the prognostic impact of WRF on CKD.

MMP-2 and TIMP-2 in patients with heart failure and chronic kidney disease

“…HF has several negative effects on kidney function but, at the same time, CKD can significantly impair cardiac function. This process is due to hemodynamic alterations, inflammatory and endothelial activation, parenchymal damage, increased neuroendocrine activity and other factors, which can influence in different ways the improvement or the worsening of both HF and CKD [ 37 ].…”

Different Relevance of Peripheral, Central or Nighttime Blood Pressure Measurements in the Prediction of Chronic Kidney Disease Progression in Patients with Mild or No-Proteinuria

“…These patients are more susceptible for damage caused by hypertension because of the failure of intrarenal blood flow autoregulation due to activation of the tubulo-glomerular feedback which leads to opening the pre-glomerular capillaries and easier transmission of the systemic hypertension directly to the glomeruli. It was shown that increased intra-glomerular pressure is one of the leading factors in the pathogenesis of faster progression of CKD [35, 36]. …”

Urinary levels of novel kidney biomarkers and risk of true worsening renal function and mortality in patients with acute heart failure

“…Although deterioration in renal function is one of the most important co‐morbidities and often complicates the natural course of hospital stay in patients with acute heart failure (AHF), the terminology and optimal assessment of renal function in this clinical condition remain controversial . In everyday practice, serum creatinine is used to monitor renal function, with a rise in its level traditionally considered as indicating worsening renal function (WRF) and linked with inevitably poor outcomes .…”