Cyclical cardiorenal syndrome in late-stage kidney disease


In patients with late-stage chronic kidney disease (LS-CKD, estimated glomerular filtration rate (eGFR) < 30 mL/min) there is a high prevalence of congestive heart failure (CHF). We have observed a cyclical nature in the "cardiorenal syndrome" in LS-CKD, not previously described. The purpose of this article is to describe the syndrome and review its characteristics.

Patients enrolled in the Northwell Health Healthy Transitions in Late Stage Kidney Disease Program (HT) were followed, all with eGFR 0 - 30 mL/min. Patients were observed for a 1-year period for signs of destabilized cardiorenal syndrome. The primary outcome of interest was an episode of cyclical cardiorenal syndrome (CCRS), defined as CHF symptoms leading to increased diuretic dose or increased renin-angiotensin-aldosterone system inhibitors (RAASi) followed within 60 days by acute kidney failure (AKI), or, conversely, an episode of AKI with reduction in diuretic or RAASi, followed within 60 days by worsening of CHF.

Of 302 HT patients, 63 (20.9%) patients had at least one episode of CCRS. Of the 63 patients, there were 89 CCRS episodes (ranging 1 - 3 per patient) and 32 (35.0%) associated hospitalizations for CHF. Of 89 CCRS episodes, 67 (75.3%) started with an episode of CHF, 22 (24.7%) started with AKI. Of 67 cases of CHF with subsequent AKI, the associated medication change was a diuretic dose increase in 61 cases (91.0%), increase in RAASi dose in 3 cases (4.5%), and increases in both in 3 cases (4.5%). Of 22 cases of AKI leading to subsequent CHF, the associated medication change was a diuretic dose decrease in 19 (86.4%) and a decrease in both diuretic and RAASi dose in 3 (13.6%).

CCRS occurs in ~ 1/5 of late-stage CKD patients with CHF. Further study would help to elucidate the extent to which fragmented care between cardiologists and nephrologists contributes to the problem.
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