Elsevier

Seminars in Nephrology

Volume 32, Issue 1, January 2012, Pages 40-48
Seminars in Nephrology

Cardio-Renal Syndrome Type 4: Epidemiology, Pathophysiology and Treatment

https://doi.org/10.1016/j.semnephrol.2011.11.006Get rights and content

Summary

Cardiovascular diseases such as coronary artery disease, congestive heart failure, arrhythmia, and sudden cardiac death represent the leading causes of morbidity and mortality in patients with CKD, increasing sharply as patients approach end-stage renal disease. The pathogenesis includes a complex, bidirectional interaction between the heart and kidneys that encompasses traditional and nontraditional risk factors, and has been termed cardio-renal syndrome type 4. In this review, an overview of the epidemiology and scope of this problem is provided, some suggested mechanisms for the pathophysiology of this disorder are discussed, and some of the key treatment strategies are described, with particular focus on recent clinical trials, both negative and positive.

Section snippets

Epidemiology

The association between CKD and increased risk for cardiac disease and events has long been recognized. In the current era, cardiovascular causes represent close to 50% of deaths in all age groups of CKD patients.3 Many patients progress through CKD and ultimately initiate dialysis with significant underlying cardiovascular disease, in part owing to the aging population and high prevalence of diabetes and other traditional risk factors such as hypertension and dyslipidemia. Illustrating this

Pathophysiology

Having identified the scope and significance of this burden of CRS type 4, it is important to examine the potential mechanisms that could be responsible for the increase in cardiovascular disease, congestive heart failure, and arrhythmia. In terms of ischemic heart disease and congestive heart failure, as mentioned before, the relationship between advancing kidney disease and heart disease may be one of shared or common risk factors, a reflection of widespread vascular disease and endothelial

Treatment

The management of CRS type 4 requires a multidisciplinary, multifaceted approach. Because of the presence of so-called traditional cardiovascular risk factors, these represent an obvious target for therapy, as they would in the general population. These typically are divided into fixed factors that are inherent to the individual, such as genetic factors, sex, age, and family history, and those that are acquired and therefore may be potentially modifiable, such as lipids, lifestyle factors, and

Conclusions

Type 4 CRS or chronic renocardiac syndrome represents a burden of cardiovascular diseases under which CKD and ESRD patients suffer that is disproportionate to the risk expected based on comorbid illnesses and Framingham risk profile. Higher than expected rates of ischemic cardiac events, congestive heart failure, left ventricular hypertrophy, cardiac arrhythmias, and sudden death plague all levels of CKD, increasing steeply as kidney function declines. The pathophysiology of CRS type 4 is

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