Multimodal Strategies for the Diagnosis and Management of Refractory Congestion. An Integrated Cardiorenal Approach

Figures

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  FIGURE 1. Cardiorenal pathophysiology. Interrelation between heart and kidney in the development of the different types of cardiorenal syndrome (CRS). Type 1 and type 2 CRS are described as acute (Chioncel et al., 2017) or chronic (Mullens et al., 2019) heart failure resulting in acute kidney injury (AKI) or chronic kidney disease (CKD). Type 3 and 4 CRS are known as acute and chronic renocardiac syndrome and are described as AKI (Abraham et al., 2011) or CKD (Melenovsky et al., 2015), resulting in heart failure. Type 5 is known as secondary CRS, and it is described as a systemic process resulting in heart and kidney failure. The classification by Hatamizadeh et al. proposes seven disease categories that contribute to CRS: hemodynamic (heart failure), uremia and kidney failure, atherosclerosis, endothelial dysfunction, neurohumoral, anemia and iron disorders, mineral disorders (FGF23, phosphorus or vitamin D disorders), and inflammatory pathways leading to malnutrition.

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  FIGURE 2. Abdominal ultrasound-guided diagnosis of volume status and its severity by assessing the inferior vena cava’s diameter, followed by Doppler evaluation of portal, hepatic and renal interlobar vein waves.

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  FIGURE 3. A multimodal approach using clinical assessment, biomarkers, and imaging tools to diagnose heart failure and kidney disease congestion and its stepwise therapeutic algorithm. CO, cardiac output; eGFR, estimated glomerular filtration rate; HCO3, bicarbonate; HD, hemodialysis; HJR, hepatojugular reflux; IV, intravenous; IVC, inferior vena cava; JVD, jugular vein distention; K, potassium; MCS, mechanical circulatory support; MRA, mineral receptor antagonist; Na, sodium; NaCl, sodium chloride; UF, ultrafiltration; UO, urinary output; *Adapted from the ESC Guidelines for the diagnosis and treatment of chronic heart failure 2021.