You probably know Kenar Jhaveri. He is the founder of NephronPower and the first editor of AJKDblog. He is a professor of Medicine at Hofstra Northwell School of Medicine on Long Island. Kenar is a good friend and one of the great nephrology educators.
He is sponsoring a cardiorenal symposium in March. I’d love to go but I’ll be most of the way to Everest Basecamp at that time. If you have some spare conference time, you should check out The Heart-Kidney Connection.
There will be mad tweeting so in mid-March tune your Twitter machine to #nephcards2018
I gave the cardiology fellows at St John Hospital and Medical Center a lecture on cardiorenal syndrome this morning. I revised and expanded the lecture I used for the residents:
It could still use a slide or two on the various loop diuretics and their uses.
We also had an interesting discussion on the data suggesting that loop diuretics maybe harmful in acute decompensated heart failure. I should include a couple of slides on that.
Overall a significant upgrade. You can find the lecture in the usual place.
On the first Friday of every month I give a lecture to the residents at St. John Hospital and Medical Center. I like to do an electrolyte lecture but for March the chief resident asked me to talk about cardiorenal syndrome. In researching the lecture I came across this article by Claudio Ronco.
The article defines cardiorenal syndrome as any condition with simultaneous kidney and heart failure. He then goes on to subdivide cardiorenal syndrome into 5 types:
- Acute heart failure causing acute renal failure
- Chronic heart failure causing chronic kidney disease
- Acute kidney injury causing any type of acute cardiac dysfunction (including arrhythmia)
- Chronic kidney disease causing any chronic cardiac disease
- Any systemic condition that causes renal and cardiac dysfuction (e.g. sepsis)
This is terrible. Cardiorenal syndrome used to signify the unique cause of acute kidney injury where the decrease in function is due to apparent volume depletion in a patient that obviously overloaded. It named the only scenario where acute kidney injury responded to diuresis. It was unique and specific. Ronco comes along and says, yes I like your version of cardiorenal syndrome so I will make it type 1 in my new all purpose definition of cardiorenal syndrome. Now whenever there is cardiac dysfunction and simultaneous kidney dysfunction we can just call it cardiorenal syndrome.
It doesn’t have to be this way look at the example of hepatorenal syndrome. The syndrome does not refere to just any situation with simultaneous renal and liver dysfunction. It is a very specific diagnosis that only occurs with chronic liver disease and ascites. The patients must be oliguric, there is no non-oliguric HRS. Patients must be sodium avid and unresponsive to fluids and albumin. Additionally the patients cannot have laboratory or imaging evidence for an alternative cause of renal failure. Because of this definition hepatorenal syndrome identifies a very specific disorder, with a specific pathophysiology and unique prognosis and treatment options.
Ronco takes the beautiful and evocative name cardiorenal syndrome, strips it of all specificity and then tries to restore it by tacking on five different types. The fifth type 5 is the one that makes my brain explode. Sepsis, really? Acute kidney injury from sepsis that happens in the same patient who also suffers from sepsis induced cardiomyopathy should now be considered to have cardiorenal syndrome? Ronco is a man who has spent his life studying sepsis and acute renal failure, I can’t believe he is actually referring to that condition as CRS type 5.
I’m not buying what Ronco’s selling. Cardiorenal syndrome begins and ends with type 1 for me.
FYI: Here is the lecture (Keynote, PDF). It still needs some work. I’d like to add a section on ultrafiltration and I need to include the NEJM article on furosemide that was published yesterday.