When, how, and why is it necessary to assess kidney function in cardiovascular patients?

7th International Congress of Cardionephrology KARNEF (2025) [pp. 174-181]

AUTHOR(S) / AUTOR(I): Jelena Nesović Ostojić , Sanjin Kovačević, Nikola Mitović, Aleksandra Nenadović, Andrija Vuković, Mirjana Jovanović

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DOI: 10.46793/KARNEF25.182NO

ABSTRACT / SAŽETAK:

Renal function is an important aspect to evaluate in cardiovascular patients because kidney function and heart function are closely interconnected. Cardiorenal syndrome refers to this complex relationship, where either heart or kidney dysfunction can lead to worsening of the other, making their management more complex and challenging. Renal function in cardiovascular patietns should be assessed at the time of diagnosis of cardiovascular conditions (e.g., heart failure, coronary artery disease, or hypertension), as kidney function can impact the treatment plan and prognosis; during hospitalization, when patietns are admitted for conditions like heart failure, renal function should be evaluated to monitor for acute kidney injury (AKI) or worsening chronic kidney disease (CKD). After surgeries such as coronary artery bypass grafting or valve replacement, renal function should be closely monitored due to the risk of postoperative renal complications. If a patient with known cardiovascular disease develops new or worsening symptoms (e.g., edema, dyspnea, or fatigue), renal function should be evaluated as it may indicate worsening heart failure or fluid overload. Certain cardiovascular drugs (like ACE inhibitors, ARBs, diuretics, and anticoagulants) are cleared by the kidneys, and renal function should be assessed to adjust doses and minimize the risk of toxicity. For patients with a known history of CKD, regular renal function evaluation is important for monitoring disease progression and managing cardiovascular risk. It is also essential to regularly evaluate renal function in patients with hypertension, diabetes, or metabolic syndrome that are risk factors for both cardiovascular and kidney diseases. Evaluating renal function in cardiovascular patients is essential to: detect and manage cardiorenal syndrome early; adjust cardiovascular medication dosages and avoid toxicities; guide fluid and electrolyte management; reduce cardiovascular and renal complications, and imrove prognosis and quality of life. By closely monitoring renal function, clinicians can optimize both cardiovascular and renal outcomes, helping to prevent complications and improve the overall health of these patients. Serum creatinine is a standard measure of kidney function. From serum creatinine, the eGFR is calculated to assess kidney function. A decline in eGFR (usually <60 mL/min/1.73m²) indicates reduced kidney function. eGFR may be overestimated in patients with high muscle mass or malnutrition, and underestimating kidney function in patients with obesity or edema. Particularly in hospitalized or critically ill patients, urine output is an important marker of renal function. Decreased urine output (oliguria) may indicate acute kidney injury or worsening heart failure. Proteinuria and hematuria can indicate kidney damage. In patients with heart failure, proteinuria may be a sign of kidney involvement and should be assessed regularly. BUN is another marker of kidney function but is less specific than creatinine and can be influenced by factors such as dehydration, diet, and liver function. Electrolytes (e.g., potassium, sodium, and bicarbonate) should be monitored, as disturbances in electrolyte balance (e.g., hyperkalemia, hyponatremia) are common in patients with kidney dysfunction and heart failure. Neurohormonal biomarkers like BNP (B-type natriuretic peptide) or proBNP can be elevated in both heart failure and renal dysfunction. Evaluating these levels can help assess the severity of heart failure and guide management. A rise in creatinine levels or a decrease in urine output can indicate AKI. Monitoring trends in these values can help in early identification and intervention. Risk scoring: Use of scoring systems like the RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease) or AKIN (Acute Kidney Injury Network) criteria may help in determining the severity of AKI.

KEYWORDS / KLJUČNE REČI:

kidney function, serum creatinine, glomerural filtration, electrolytes, neurohormonal biomarkers, carciovascular patients

REFERENCES / LITERATURA:

  • Boudoulas KD, Boudoulas H. Cardiorenal interrelation ship. Cardiology 2011; 120:135–138.
  • Deferrari G, Cipriani A, La Porta E. Renal dysfunction in cardiovascular diseases and its consequences. J Nephrol 2021; 34:137–53.
  • Ronco C, Haapio M, House AA, Anavekar N, Bellomo R. Cardiorenal syndrome. JACC 2008; 52:1527–1539.
  • Zoccali C, Vanholder R, Massy ZA, Ortiz A, Sarafidis P et al. The systemic nature of CKD. Nat Rev Nephrol 2017; 13:344–358.
  • Zoccali C. Cardiorenal risk as a new frontier of neph rology: research needs and areas for intervention. Nephrol Dial Transplant 2002; 17(S11):50–54.
  • Hatamizadeh P, Fonarow GC, Budoff MJ, Darabian S, Kovesdy CP et al. Cardiorenal syndrome: pathophysiology and potential targets for clinical management. Nat Rev Nephrol 2013; 9:99–111.
  • Aronson D, Burger AJ. The relationship between transient and persistent worsening renal function and mortality in patients with acute decompensated heart failure. J Card Fail 2010; 16:541–547.
  • Aronson D, Mittleman MA, Burger AJ. Elevated blood urea nitrogen level as a predictor of mortality in patients admitted for decompensated heart failure. Am J Med 2004; 116:466–473.
  • Matsue Y, van der Meer P, Damman K, Metra M, O’Connor CM et al. Blood urea nitrogen-to-creatinine ratio in the general population and in patients with acute heart failure. Heart 2017; 103:407–413.
  • Kenneally LF, Lorenzo M, Romero-Gonzalez G, et al. Kidney function changes in acute heart failure: a practical approach to interpretation and management. Clin Kidney J 2023; 16(10):1587-99.
  • Núñez J, Llàcer P, Núñez E et al. Antigen carbohydrate 125 and creatinine on admission for prediction of re nal function response following loop diuretic administra tion in acute heart failure. Int J Cardiol 2014; 174:516–23.
  • Damman K,Ng Kam Chuen MJ,MacFadyen RJ et al.Volume status and diuretic therapy in systolic heart failure and the detection of early abnormalities in renal and tubular func tion. J Am Coll Cardiol 2011; 57:2233–41.
  • Núñez J, Llàcer P, Núñez E et al. Antigen carbohydrate 125 and creatinine on admission for prediction of renal function response following loop diuretic administration in acute heart failure. Int J Cardiol 2014; 174:516–23.
  • Núñez J, Núñez E, Miñana G et al. Differential mortal ity association of loop diuretic dosage according to blood urea nitrogen and carbohydrate antigen 125 following a hospitalization for acute heart failure. Eur J Heart Fail 2012; 14:974–84.
  • Núñez J, Llàcer P, García-Blas S et al. CA125-guided diuretic treatment versus usual care in patients with acute heart failure andrenal dysfunction. Am J Med 2020; 133:370–80.e4.
  • Wettersten N, Horiuchi Y, van Veldhuisen DJ et al. B type natriuretic peptide trend predicts clinical signifi cance of worsening renal function in acute heart failure. Eur J Heart Fail 2019; 21:1553–60.
  • McCallum W, Tighiouart H, Kiernan MS et al. Relation of kidney function decline and NT-proBNP with risk of mor tality and readmission in acute decompensated heart fail ure. Am J Med 2020; 133:115–122.e2.
  • Ambrosy AP, Pang PS, Khan S et al. Clinical course and predictive value of congestion during hospitalization in patients admitted for worsening signs and symptoms of heart failure with reduced ejection fraction: findings from the EVEREST trial. Eur Heart J 2013; 34:835–43.
  • Lala A, McNulty SE, Mentz RJ et al. Relief and recurrence of congestion during and after hospitalization for acute heart failure: insights from Diuretic Optimization Strategy Evaluation in Acute Decompensated Heart Failure (DOSE AHF) and Cardiorenal Rescue Study in Acute Decompen sated Heart Failure (CARESS-HF). Circ Heart Fail 2015; 8:741-8.
  • Rubio-Gracia J, Demissei BG, ter Maaten JM et al. Preva lence, predictors and clinical outcome of residual con gestion in acute decompensated heart failure. Int J Car diol 2018; 258:185–91.
  • Mullens W, Damman K, Harjola VP et al. The use of di uretics in heart failure with congestion– a position state ment from the Heart Failure Association of the Euro pean Society of Cardiology. Eur J Heart Fail 2019; 21:137–55.
  • Damman K, Navis G,Voors AA et al.Worsening renal func tion and prognosis in heart failure: systematic review and meta-analysis. J Card Fail 2007; 13:599–608.
  • Núñez J, Garcia S, Núñez E et al. Early serum creatinine changes and outcomes in patients admitted for acute heart failure: the cardio-renal syndrome revisited. Eur Heart J Acute Cardiovasc Care 2017; 6:430–40.
  • Chawla LS, Bellomo R, Bihorac A et al. Acute kidney disease and renal recovery: consensus report of the Acute Disease Quality Initiative (ADQI) 16 Workgroup. Nat Rev Nephrol 2017; 13:241–57.
  • Felker GM, Lee KL, Bull DA et al. Diuretic strategies in patients with acute decompensated heart failure. N Engl J Med 2011; 364:797–805.
  • Mullens W, Dauw J, Martens P et al. Acetazolamide in acute decompensated heart failure with volume over load. N Engl J Med 2022; 387:1185–95.
  • Voors AA, Damman K,Teerlink JR et al. Renal effects of empagliflozin in patients hospitalized for acute heart failure: from the EMPU LSE trial. Eur J Heart Fail 2022; 24:1844–52.
  • Metra M, Cotter G, Senger S, Edwards C, Cleland JG et al. Prognostic significance of creatinine increases during an acute heart failure admission in patients with and without residual con gestion: a post hoc analysis of the PROTECT data. Circ Heart Fail 2018; 11:e004644.
  • Choi JS, Kim YA, Kim MJ, Kang YU, Kim CS et al. Relation between transient or persistent acute kidney injury and long-term mortality in patients with myocardial infarction. Am J Cardiol 2013; 112:41–45 82.
  • Logeart D, Tabet JY, Hittinger L, Thabut G, Jourdain P et al. Transient worsening of renal function during hospi talization for acute heart failure alters outcome. Int J Cardiol 2008; 127:228–232 83.
  • Lanfear DE, Peterson EL, Campbell J, Phatak H, Wu D et al. Relation of worsened renal function during hospitaliza tion for heart failure to long-term outcomes and rehospitalization. Am J Cardiol 2011; 107:74–78.
  • Fudim M, Loungani R, Doerfler SM, Coles A, Greene SJ et al. Worsening renal function during decongestion among patients hospitalized for heart failure: findings from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial. Am Heart J 2018; 204:163–173.
  • Damman K, Solomon SD, Pfeffer MA, Swedberg K, Yusuf S et al. Worsening renal function and outcome in heart failure patients with reduced and preserved ejection fraction and the impact of angiotensin receptor blocker treatment: data from the CHARM-study programme. Eur J Heart Fail 2016; 18:1508–1517.
  • Beldhuis IE, Streng KW, Ter Maaten JM, Voors AA, van der Meer P et al. Renin-angiotensin system inhibition, wors ening renal function, and outcome in heart failure patients with reduced and preserved ejection fraction: a meta-analysis of pub lished study data. Circ Heart Fail 2017; 10:e003588.
  • Newsome BB, Warnock DG, McClellan WM, Herzog CA, Kiefe CI. Long-term risk of mortality and end-stage renal dis ease among the elderly after small increases in serum creatinine level during hospitalization for acute myocardial infarction. Arch Intern Med 2008; 168:609–616.
  • Maisel A, Mueller C, Adams K Jr, Anker SD, Aspromonte N, Cleland JG, et al. State of the art: using natriuretic peptide levels in clinical practice. Eur J Heart Fail. 2008;10:824–39.
  • Van Kimmenade RR, Januzzi JL, Bakker JA, Houben AJ, Rennenberg R, Kroon AA, et al. Renal clearance of B-type natriuretic peptide and amino terminal pro-B-type natriuretic peptide. J Am Coll Cardiol 2009; 53:884–90.
  • Vodovar N, Seronde MF, Laribi S, Gayat E, Lassus J, Januzzi JL Jr, et al. Elevated plasma B-type natriuretic peptide concentrations directly inhibit circulating neprilysin activity in heart failure. JACC: Heart Fail 2015; 3:629–36.
  • Emrich IE, Vodovar N, Feuer L, Untersteller K, Nougué H, Seiler-Mussler S, et al. Do plasma neprilysin activity and plasma neprilysin concentration predict cardiac events in chronic kidney disease patients? Nephrol Dial Transplant 2019; 34:100–8.
  • Romero-González G, Ravassa S, González O, et al. Burden and challanges of heart failure in patients with chronic kidney disease. A call to action. Nefrologia 2020; 40(3):223-236.
  • Costanzo MR, Ronco C, Abraham WT, Agostoni P, Barasch J, Fonarow GC, et al. Extracorporeal ultrafiltration for fluid overload in heart failure: current status and prospects for further research. J Am Coll Cardiol 2017; 69:2428–45.
  • Brisco MA, Zile MR, Hanberg JS, Wilson P, Parikh CR, Coca SG, et al. Relevance of changes in serum creatinine during a heart failure trial of decongestive strategies: insights from the DOSE trial. J Card Fail 2016; 22:753–60.
  • Arrigo M, Cippà PE, Mebazaa A. Cardiorenal interactions revisited: how to improve heart failure outcomes in patients with chronic kidney disease. Circ Heart Fail Rep. 2018; 15:307–14.
  • Costanzo MR, Guglin ME, Saltzberg MT, Jessup ML, Bart BA, Teerlink JR, et al. Ultrafiltration versus intravenous diuretics for patients hospitalized for acute decompensated heart failure. J Am Coll Cardiol 2007; 49:675–83.
  • Costanzo MR, Negoianu D, Jaski BE, Bart BA, Heywood JT, Anand IS, et al. Aquapheresis versus intravenous diuretics and hospitalizations for heart failure. JACC Heart Fail 2016; 4:95–105.
  • Marenzi G, Muratori M, Cosentino ER, Rinaldi ER, Donghi V, Milazzo V, et al. Continuous ultrafiltration for congestive heart failure: the CUORE trial. J Card Fail 2014; 20:9–17.
  • Grodin JL, Carter S, Bart BA, Goldsmith SR, Drazner MH, Tang WH. Comparison of ultrafiltration to pharmacological decongestion in heart failure: a per-protocol analysis of CARRESS-HF. Eur J Heart Fail 2018; 20:1148–56.
  • Lu R, Mucino-Bermejo MJ, Ribeiro LC, Tonini E, Estremadoyro C, Samoni S, et al. Peritoneal dialysis in patients with refractory congestive heart failure: a systematic review. Cardiorenal Med 2015; 5:145–56.
  • Zuidema MY, Dellsperger KC. Myocardial stunning with hemodialysis: clinical challenges of the cardiorenal patient. Cardiorenal Med 2012; 2:125–33.
  • Braunwald E, Kloner RA. The stunned myocardium: prolonged, postischemic ventricular dysfunction. Circulation 1982; 66:1146–9.
  • Burton JO, Jefferies HJ, Selby NM, McIntyre CW. Hemodialysis-induced repetitive myocardial injury results in global and segmental reduction in systolic cardiac function. Clin J Am Soc Nephrol 2009; 4:1925–31.
  • Flythe JE, Xue H, Lynch KE, Curhan GC, Brunelli SM. Association of mortality risk with various definitions of intradialytic hypotension. J Am Soc Nephrol 2015; 26:724–34.
  • Stefánsson BV, Brunelli SM, Cabrera C, Rosenbaum D, Anum E, Ramakrishnan K, et al. Intradialytic hypotension and risk of cardiovascular disease. Clin J Am Soc Nephrol 2014; 9:2124–32.
  • Takahama H, Kitakaze M. Pathophysiology of cardiorenal syndrome in patients with heart failure: potential therapeutic targets. Am J Physiol Heart Circ Physiol 2017; 313:H715–21.
  • López B, González A, Querejeta R, Larman M, Rábago G, Díez J. Association of cardiotrophin-1 with myocardial fibrosis in hypertensive patients with heart failure. Hypertension 2014; 63:483–9.
  • López B, González A, Querejeta R, Barba J, Díez J. Association of plasma cardiotrophin-1 with stage C heart failure in hypertensive patients: potential diagnostic implications. J Hypertens 2009; 27:418–24.
  • Palazzuoli A, Lombardi C, Ruocco G, Padeletti M, Nuti R, Metra M, et al. Chronic kidney disease and worsening renal function in acute heart failure: different phenotypes with similar prognostic impact? Eur Heart J Acute Cardiovasc Care 2016; 5:534–48.
  • Mentz RJ, O’Connor CM. Pathophysiology and clinical evaluation of acute heart failure. Nat Rev Cardiol 2016; 13:28–35.