Cardiorenal (CRS) and Renocardiac (RCS) syndrome and challenges in patient management

Abstract

Introduction: Cardiorenal syndromes (CRS) are disorders of the heart and kidneys whereby acute or long-term dysfunction in one organ may induce acute or long-term dysfunction of the other. CRS is characterized by the triad of concomitant decreased kidney function, therapy-resistant heart failure with congestion (diuretic resistance), and worsening kidney function during heart failure therapy. Once developed CRS is associated with a poor clinical outcome. Case Presentation: A 62-year-old man with coronary artery disease (previous myocardial infarction) and heart failure was admitted to the Intensive care unit (ICU) because of progressive dyspnoea and worsening peripheral oedema. Medical history included type 2 diabetes with micro- and macroangiopathic complications - retinopathy, polyneuropathy, nephropathy. On admission increased blood pressure with bilateral lower-limb pitting oedema, tachycardia and tachypnea was detected. Serum creatinine level, previously stable at approximately 180 I¼mol/L; was now 413 I¼mol/L, with serum urea level 20.1 mmol/l. Results: After admission to the ICU, due to deterioration of respiratory function the patient was intubated, sedated and mechanically ventilated. A furosemide infusion was started with increasing doses (up to 15 mg/h); however, diuresis remained poor (500 mL/24 h). Due to elevated levels of blood pressure, high-dose Nitroglycerine infusions were started. After 10 days in the hospital without satisfactory clinical improvement and with increasing creatinine level (653 I¼mol/L), and decreased urine output, reno-replacement therapy was started. On the 30th day of the ICU stay due to dyselectrolytaemia and ventricular fibrillation the patient passed away. Conclusion: The various subtypes of CRS present unique challenges because therapies directed at one organ may have beneficial or detrimental effects on the other. The complexity of care, poor clinical outcome and high mortality rate demands a multidisciplinary approach, combining the expertise of cardiology, nephrology, and critical care.