What Is The Relationship Between Heart Disease And Kidney Disease

The intricate link between heart and kidney function was highlighted as early as 1836 by Sir Richard Bright, who made astute observations on the myriad structural changes in the heart of patients with renal atrophy. Since the literature, the field of cardiorenal medicine has made significant advances in defining mechanisms of cross-talk between the heart and kidney, building on the solid foundation of physiological experiments at the beginning of the 20th century that laid the foundation for our current understanding of the pathophysiology of cardiorenal syndrome through hemodynamic, inflammatory, and adverse neurohormonal pathways. These observations were further investigated and validated in the clinical setting and formed the basis for the phenotype of the cardiorenal syndrome (CRS), a subtype based on the "primary driver" of the disease (heart versus kidney), the acuity of the syndrome, and the presence or absence of systemic multi-organ involvement.

At the same time, the field of cardiorenal disease has expanded beyond the syndrome itself, which is centered on the kidney's response to the failing heart, to cardiovascular disease that examines all phenotypes of patients with kidney disease, including coronary artery disease, valvular disease and arrhythmias, healthcare resource utilization, economics, and precision medicine analysis of patients with dual heart and kidney disease. This expansion was inevitable given the increasing prevalence of vascular risk factors such as diabetes, hypertension, and obesity, which constitute a common ground for the development and maintenance of cardiovascular and renal disease.

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The scope of cardiorenal medicine is now rapidly expanding to include early risk mitigation (primary and primary prevention), aggressive secondary prevention, cardiorenal therapy for high-risk patients, such as dialysis for patients with left ventricular assist devices, and an emphasis on patient and caregiver involvement in decision-making as part of a multidisciplinary approach to care that emphasizes individualized goals and quality of life. Superimposed on the existing cardiac and renal disease landscape, the additional burden of COVID-19 brings to the forefront the limitations of current healthcare delivery, suboptimal control of cardiac and renal disease risk factors, and fragmentation of care for patients with complex cardiac and renal disease, highlighting the urgent need for a comprehensive overhaul of our approach to optimizing care for these vulnerable patients.

The manuscript by Kazory A and Costanzo MR describes the role of chloride as a cardiorenal connector, prognostic marker, and potential therapeutic target, with the nuances of disease-modifying therapies in cardiorenal hemodynamics and CRS occupying the forefront of attention. Toroghi HM. et al. describe the use of newer predictors of renal function, such as pulmonary artery capacitance, in patients with heart failure with preserved ejection fraction. This reveals the utility of new markers of right ventricular function as potential options for the prognosis of renal function across the entire spectrum of heart failure, regardless of ejection fraction, which may have implications for the selection of guideline-guided medical therapy (GDMT) in these patients. Maintenance, escalation, and downgrading of renin-angiotensin system inhibitors is an uncertain topic in real-world practice, with different practice patterns between cardiology and nephrology.

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To this end, the review by Singha nia G et al on the continued use of renin-angiotensin system inhibitors (RASi) in patients with acute heart failure (AHF) is an important contribution to the literature and highlights the need to ensure that vulnerable patients with AHF benefit from continued use of GDMT as well as appropriate decongestive therapy.

Similarly, the manuscript by Lo KB et al. describes the pattern of RASi use in AHF, and data from right heart catheterization describe the hemodynamic profile of these patients and confirm the deleterious effects of continued congestion and discontinuation of RASi in AHF, which include high mortality rates in hospitalized patients and 6-month HF readmission rates.HF management in patients with ESKD is of higher complexity and faces the challenge of determining an accurate diagnosis, given that these patients are excluded from the primary RCS for HF, implementing GDMT with limited high-quality data, and focusing on patient goals and quality of life. In their detailed review of this topic, Joseph MS et al. use a practical and data-driven approach to point out the nuances of the diagnosis and management of heart failure (HF) in ESKD, which are important for the care of cardiologists and nephrologists who care for these high-risk patients is certainly an extremely valuable resource.

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The importance of CKD as an independent risk factor for coronary artery disease (CAD) has been well described in the literature. However, the high burden of coronary microvascular dysfunction in patients with CKD has not received sufficient attention. in their manuscript on accelerated and exacerbated calcified atherosclerosis and microvascular dysfunction in patients with CKD, Fakhry M. et al. beautifully describe the pathophysiological processes driving the accelerated and disproportionate burden of CAD in patients with CKD and highlight future areas of research on microvascular dysfunction.

Finally, the importance of insulin resistance as a key factor contributing to the elevated risk of cardiovascular disease in patients with CKD and glomerular hyperfiltration, as well as Adeva-Andany M. et al. and Chuang a . et al. respectively, suggest the utility of high-sensitivity troponin assays in CKD, reflecting a new role for cardiac and renal disease biomarkers that will help us understand the complex interactions between the heart and kidney in the future.

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In life, we should pay special attention to protecting our kidneys. Cistanche has been shown to help protect the kidneys and greatly reduce the risk of kidney disease. Cistanche tubular contains a lot of Phenylethanol total glycosides Echinoside and Verbascoside which are beneficial to the kidney. In the meantime, we should also take Cistanche extract in the appropriate dosage under the doctor's orders.

REFERENCES

[1] Bright R. Cases and observations illustrative of renal disease accompanied by the secretion of albuminous urine. Guy’s Hospital Reports. 1836; 10: 338–400.

[2] Rangaswami J, Mathew RO. Pathophysiological mechanisms in cardiorenal syndrome. Advances in Chronic Kidney Disease. 2019; 25: 400–407.

[3] Rangaswami J, Bhalla V, Blair JEA, Chang TI, Costa S, Lentine KL, et al. Cardiorenal syndrome: classification, pathophysiology, diagnosis, and treatment strategies: a scientific statement from the

American Heart Association. Circulation. 2019; 139: e840–e878.

[4] Drozd M, Pujades-Rodriguez M, Lillie PJ, Straw S, Morgan AW, Kearney MT, et al. Non-communicable disease, sociodemographic factors, and risk of death from infection: a UK Biobank observational cohort study. The Lancet Infectious Diseases. 2021. (in press)

[5] Kazory A, Costanzo MR. The dynamic relationship between serum chloride and cardiorenal syndrome. Reviews in Cardiovascular Medicine. 2020; 21: 25–29.

[6] Toroghi HM, Lo KB, Ziccardi MR, Horn B, Kanjanahattakij N, Malik E,et al. Renal implications of pulmonary arterial capacitance in acute heart failure with preserved ejection fraction. Reviews in Cardiovascular Medicine. 2019; 20: 267–272.

[7] Lo KB, Toroghi HM, Salacup G, Jiang J, Bhargav R, Quintero E, et al. Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in acute heart failure: invasive hemodynamic parameters and clinical outcomes. Reviews Cardiovascular Medicine. 2021; 22: 199–206.

[8] Joseph MS, Palardy M, Bhave NM. Management of heart failure in patients with end-stage kidney disease on maintenance dialysis: a practical guide. Reviews in Cardiovascular Medicine. 2020; 21: 31–39.

[9] Fakhry M, Sidhu MS, Bangalore S, Mathew RO. Accelerated and intensified calcific atherosclerosis and microvascular dysfunction in patients with chronic kidney disease. Reviews in Cardiovascular Medicine. 2020; 21: 157–162.

[10] Adeva-Andany MM, Fernández-Fernández C, Carneiro-Freire N, Castro-Quintela E, Pedre-Piñeiro A, Seco-Filgueira M. Insulin resistance underlies the elevated cardiovascular risk associated with kidney disease and glomerular hyperfiltration. Reviews in Cardiovascular Medicine. 2020; 21: 41–56.