ACEI in cardiorenal syndrome

In this article, the literature is reviewed regarding the role of blood pressure variability and nocturnal nondipping of blood pressure as well as the presence of diabetic kidney disease (DKD), in the absence of albuminuria, as risk predictors for progressive DKD. The importance of glycemic and blood pressure control in patients with diabetes and chronic kidney disease, and the use of oral hypoglycemic agents and antihypertensive agents in this patient cohort, are also discussed.

Interactions between the heart and the kidneys are increasingly acknowledged among both cardiologists and nephrologists. The term cardiorenal syndrome now applies to the bidirectional nature of how disease in one organ system affects the function of the other organ system. Cardiovascular disease is a major threat to patients with chronic kidney disease, while renal dysfunction is prevalent in patients with cardiac disease and is a significant predictor of prognosis in cardiac patients. Still, renal patients with cardiac disease have largely been excluded from the clinical trials that have been the basis of modern cardiologic treatment...

An altered ambulatory blood pressure (BP) and heart rate (HR) profile is related to chronic kidney disease (CKD) and cardiorenal syndrome. In this study, we examined the effects of aliskiren, when added to angiotensin II type 1 receptor blockers, on ambulatory BP and cardiorenal function in CKD. Thirty-six hypertensive CKD patients were randomly assigned to the aliskiren add-on group (n = 18) or the benazepril add-on group (n = 18). Ambulatory BP and cardiorenal function parameters were measured at baseline and 24 weeks after treatment...

CRS is a common problem in patients with advanced heart failure. Arterial underfilling with consequent neurohormonal activation, systemic and intrarenal vasoconstriction, and salt and water retention cause the main clinical features of CRS which include a progressive decline in renal function, worsening renal function during treatment of heart failure (HF) decompensation and resistance to loop diuretics. Impaired renal function in HF patients often reflects more advanced stages of cardiac failure, and thus is associated with a worse prognosis...

Anemia and chronic kidney disease are common in patients with heart failure (HF) and are associated with adverse outcomes. We analyzed the effect of cardiorenal anemia (CRA) syndrome, defined as anemia (hemoglobin <130 g/L for men, <120 g/L for women) and stage 3 or greater chronic kidney disease (estimated glomerular filtration rate <60 ml/min/1.73 m(2)), in outpatients with HF. Consecutive patients with HF were prospectively enrolled from 2000 to 2005 (n = 748). The baseline clinical characteristics, pathology test results, and medication use were compared between those with and without CRA syndrome...

Focus on the role of the renin-angiotensin-aldosterone system (RAAS) in the pathophysiology of hypertension and renal damage has shifted recently to the role of the local RAAS in the kidneys. Inappropriate augmentation of intrarenal RAAS activity in patients with chronic kidney disease has suggested playing important roles in the development of hypertension and renal injury. In this article, I show the recent findings that salt-induced this augmentation may contribute to the development of salt-sensitive hypertension and play a key role in cardiorenal syndrome (CRS), and that blockade of intrarenal RAAS may be an important strategy for salt-sensitive hypertension and CRS...

Diabetes mellitus coexisting with hypertension is greater than chance alone would predict. Hypertensive patients have been shown to have altered composition of skeletal muscle tissue, decreased blood flow to skeletal muscle and post-receptor signaling alterations in the IRS insulin pathway, all inducing insulin resistance states, which partially explains why blood pressure goals in DM patients are lower than in normoglycemic patients. Although optimal first-step antihypertensive drug therapy in type 2 DM or impaired fasting glucose levels (IFG) should be individualized for each patient, converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) have been demonstrated in some but not all studies to decrease the rate of development of proteinuria and diabetic renal disease...

Heart failure syndromes are often associated with multi-organ dysfunction, and concomitant liver, renal, and neurologic involvement is very common. Neuro-hormonal antagonism plays a key role in the management of this syndrome, and angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are one of the cornerstones of therapy. Cardiorenal physiology is becoming more recognized in these patients with advanced heart failure, and the role of neuro-hormonal blockade in this setting is vaguely defined in the literature...

Acute heart failure syndromes (AHFS) are a heterogeneous group of commonly encountered and difficult to manage clinical syndromes associated with high morbidity and mortality. Dyspnoea, pulmonary, and systemic congestion often characterize AHFS due to acutely elevated intracardiac filling pressures and fluid overload. Diuresis, respiratory support, vasodilator therapy, and gradual attenuation of the activation of renin-angiotensin-aldosterone system (RAAS) and sympathetic nervous system (SNS) are the keystones of AHFS management...

A growing body of evidence indicates that the metabolic syndrome and hypertension are interrelated at an epidemiological as well as pathophysiological level. Due to the high prevalence of concomitant signs of subclinical organ damage and the high risk of cardiorenal complications, hypertensive patients with metabolic syndrome are to be considered at high risk. Although the management of this condition must begin with the implementation of a healthy lifestyle and dietary habits, these measures are usually insufficient to adequately control blood pressure values and reduce the cardiovascular risk in the long term...

Chronic kidney disease (CKD) is now widely accepted as a risk factor for cardiovascular disease and mortality. Heart failure patients with CKD have a worse prognosis. The heart and kidneys act in tandem to regulate blood pressure, vascular tone, diuresis, natriuresis, intravascular volume homeostasis, peripheral tissue perfusion, and oxygenation. Cardiorenal syndrome is a pathophysiological condition in which combined cardiac and renal dysfunction amplifies the progression of failure of the individual organs, and it has an extremely poor prognosis...

In the past two decades European cardiologists have always been told to follow the evidence-based guidelines in their everyday clinical practice. In the case of patients with heart failure and concomitant renal disease, this universal rule is not easily applicable simply because there is a lack of specific trials in this field. Patients with cardiorenal syndromes are at risk of complications and have high morbidity and mortality. However, the management of these patients is often empirical. Drugs commonly recommended for the treatment of chronic and acutely decompensated heart failure are not always accepted for patients with concomitant renal disease...

Renal dysfunction is an independent risk factor of chronic cardiac failure (CCF) and death due to this disease. CCF patients are elderly patients with diabetes mellitus, arterial hypertension and long-term chronic cardiac insufficiency. CCF patients do not often have left ventricular systolic dysfunction, renal affection is not associated with low ejection syndrome. Renal affection in CCF is primarily caused by activation of the system rennin-angiotensin, inflammation, disturbed bioavailability of nitric oxide, hyperactivation of the sympathetic nervous system...

Very often, physicians confront with patients who have concomitant heart and kidney failure. The coexistence of kidney and heart failure carries an extremely bad prognosis. The exact cause of deterioration of kidney function and the mechanism underlying this interaction are complex, multifactorial in nature, and still not completely understood. Both the heart and the kidney act in tandem to regulate blood pressure, vascular tone, diuresis, natriuresis, etc. An extension to the Guytonian model of volume and blood pressure control is proposed called cardiorenal connection...

The case of a 66-year-old male with heart failure and cardiorenal syndrome is presented. The patient had normal renal function before intensive treatment with diuretics and ACE inhibitor. Shortly after the ACE inhibitor was stopped and diuretics were either stopped or reduced in dosage, his renal function normalized. Suggestions are presented for follow-up after initiation of ACE inhibitor treatment.

Nephrologists should promote the detection of CKD in heart disease patients. The evaluation should include estimation of GFR and detection of microalbuminuria in a recently voided urine sample by the albumin:creatinine ratio. Any patient with stage 3 or 4 CKD and rapid deterioration of GFR should be evaluated by the nephrologist. - Patients with CKD have a high risk of cardiovascular (CV) complications and heart disease patients have a high incidence of CKD and progression is also more rapid (Strength of Recommendation B)...

In heart failure, as the heart gets worse, often so do the kidneys, complicating the treatment of heart failure and worsening the prognosis. This article addresses challenges in the use of diuretics, angiotensin-converting enzyme (ACE) inhibitors, and other therapies in the cardiorenal syndrome, as well as novel therapies that hold promise, such as arginine vasopressin antagonists, adenosine A1 receptor antagonists, and ultrafiltration.

AIM: To elicit the role of endothelial dysfunction in development of cardiorenal syndrome in patients with diabetes mellitus type 1 (DM1) with diabetic nephropathy (DN) and to evaluate the efficacy of endotheliotropic drugs: nebivolol (a selective beta-blocker) and enalapril (ACE inhibitor). MATERIAL AND METHODS: The trial enrolled 60 patients with DM1: 15 patients with normoalbuminuria (NAU), 15 patients with microalbuminuria (MAU), 15 patients with proteinuria (PU) and 15 with chronic renal failure (CRF)...

Significant renal dysfunction is common in patients hospitalized for heart failure and carries a grim prognosis. Patients with heart failure who have or develop renal dysfunction while being treated for heart failure are said to have the cardiorenal syndrome. The Acute Decompensated Heart Failure National Registry (ADHERE) database, which enrolled nonselected patients admitted to the hospital for acute decompensated heart failure (ADHF), was used to determine the causes for this renal dysfunction and whether treatment can optimize outcomes...

Normotensive type 1 diabetics with persistent albuminuria were randomized between 12 months' treatment with low-dose fosinopril (10 mg/d) and placebo in a 24-month, double-blind, crossover trial. Metabolic and cardiovascular variables were measured every three months and two-dimensional and M-mode echocardiography was performed before and after each treatment phase. Low-dose fosinopril led to 70% reduction in urinary albumin excretion (UAE) (220 +/- 199 vs 82 +/- 67 mg/24-h, p < 0.05), but UAE did not change during placebo treatment; the maximal change became apparent after 3 months and was reversible once treatment was stopped...