The Kidney in Heart Failure Natale G

The Kidney in Heart Failure Natale G. De Santo,* Massimo Cirillo,* Alessandra Perna,* Rosa Maria Pollastro,* Annamaria Frangiosa,* Enzo Di Stazio,* Luigi Iorio,† Vito Andrea Di Leo,* and Pietro Anastasio*

Renal dysfunction is a constant feature of congestive heart failure and is a stronger predictor of mortality than left ventricular ejection fraction or New York Heart Association classification. In heart failure, a reduction of glomerular filtration rate and renal plasma flow occurs, although the filtration fraction increases. There are many reason for this pattern. A reduction in effective circulating volume stimulates sympathetic activity and the renin- angiotensin-aldosterone system, and it is associated with increased concentrations of atrial natriuretic peptide, brain natriuretic peptide, and tumor necrosis factor ␣. Because in chronic kidney disease heart dysfunction commonly is present, an efficient cardiologist- nephrologist interaction should be promoted. Semin Nephrol 25:404-407 © 2005 Elsevier Inc. All rights reserved.

KEYWORDS kidney disease, congestive heart failure, renal resistance, GFR, RPF, FF, survival rate, creatinine clearance, cardiologist-nephrologist interaction

he problem of heart failure is an old one. It is even dis- volume increases with heart failure and edema, and in 1935 Tcussed in the Corpus Hippocraticum, in which patients Peters6 noted that “the kidneys react to changes of circulating with shortness of breath, edema, anasarca, and cardiac ca- blood but are indifferent to changes in the volume of body chexia are described.1 Edema was thought to be caused by a fluids.” Shortly thereafter, it also became clear that in “heart shift of phlegm—a cold humor—from the brain into the disease there is inadequate translocation of fluid from venous chest. This theory persisted for a long time and finally came to arterial side,”7 and that the link between inadequate filling to an end with Andrea Cesalpino (1571, 1593) and William of the systemic arterial tree and edema formation is brought Harvey (1628). up by the kidneys.8 Katz2 provided a nice synopsis of the evolution of patho- However, as pointed out by Anand,9 “the effective blood physiology of heart failure over the past 2500 years. How- volume is a poorly defined entity because there are no known ever, we disagree with him in his attribution to Harvey alone mechanisms by which the body can directly monitor its in- of the theory of hemodynamics. In fact, in Quaestionum peri- adequacy and it cannot be measured. Until we can measure pateticarum (1571) and in Quaestionum medicarum (1593), effective blood volume this concept must remain hypo- Andrea Cesalpino of Arezzo (1524-1603) gave an exact dem- thetic.” onstration of the general scheme of circulation.3,4 We now know that a reduction of effective circulating The crucial step in understanding the cardiorenal axis is volume stimulates catecholamines, angiotensin II, endothe- represented by the studies of Starling,5 who in the lectures to lin, and anti diuretic hormone (ADH), which cause reduction the Royal College of Surgeon in February 1896, stated that of renal blood flow (RBF), glomerular filtration rate (GFR), “ as effect of heart failure sodium retention occurs along with and an increase of filtration fraction (FF). An increase in reduced sodium excretion. Continuous increase in circulat- proximal reabsorption occurs, followed by reduced distal ing fluid occurs till capillary pressure is restored.” However, sodium delivery and activation of the juxtaglomerular appa- in 1931 Wollheim gave the first demonstration that blood ratus.10 In 1946, Merrill11 was the first to measure GFR and renal plasma flow (RPF) in heart failure (Fig 1) and it was evident *First Division of Nephrology Second University of Naples, Naples, Italy. that RPF was more affected than GFR. The information was †Division of Nephrology, “De Bosis” Hospital, Cassino, Italy. confirmed by Aas and Blegen.12 However, it took many more Supported by Regione Campania. Address reprint requests to Natale G. De Santo, MD, 5 Via Pansini, Pad 17, years and the advent of micropuncture techniques to under- First Division of Nephrology, Second University of Naples, 80131 Na- stand the underlying tubular and glomerular mecha- ples, Italy. E-mail: [email protected] nisms.13,14

and reduced sodium excretion. ANP and BNP are considered 700 markers of heart failure. BNP has a greater specificity and may be used for diagnostic purposes. It has been shown that 600 control in patients undergoing a 40% reduction of BNP concentra- 500 CHF tion during treatment, this feature is associated with 1 class decrease in New York Heart Association (NYHA) classifica- 400 40 tion of heart failure.17 300 30 Aldosterone is sodium retaining and potassium wasting, by acting on Nedd4, which causes sodium reabsorption. In 20 200 CHF an aldosterone escape failure occurs, and aldosterone 100 10 antagonists have many beneficial effects on sodium balance and heart fibrosis.18 0 ANP and BNP increase GFR by increasing glomerular hy- inulin, PAH, FF % mL/min mL/min drostatic pressure and Kf, decrease proximal and distal sodium reabsorption, increase blood flow in vasa recta, and decrease renin release. ANP and BNP blood concentrations Figure 1 □ GFR, RPF, and FF. , control; , CHF. Data from Mer- are increased significantly in CHF. A decreased response to rill.11 ANP has been shown in human beings with CHF. Hypore- sponsiveness is of multifactorial origin, and includes a reduc- Two Suicides tion of renal perfusion pressure and an increase in renal sympathetic activity. Finally, it should be stressed that in CHF the Andreoli15 has shown nicely that in conditions of underfill- kidneys are normal, and, when transplanted in healthy indi- ing, similar to those occurring in systolic pump failure, a viduals, they operate normally. suicidal arterial filling takes place. In fact, because of the Taken together, the neurohormonal response activated in hemodynamic changes, there is an increase in afterload that CHF is identical to that which occurs after physical exercise leads to an increased end-diastolic volume. However, under- or hemorrhage.19,20 A response evolved over the millennia to filling affects sodium avidity, thus increasing preload and resist those life-threatening conditions such as hemorrhage causing an increase in end-diastolic volume, which reduces and physical exercise. Under these conditions there is an the ejection fraction. increased sympathetic activity with venoconstriction, tachy- The second suicide occurs via tumor necrosis factor ␣, cardia, myocardial stimulation, and regional vasoconstric- which triggers apoptosis, increases nitric oxide, and en- tion.9 Additionally, in CHF the threat to blood pressure is hances expression of proto-oncogenes. The synthesis of a long lasting, therefore the effector mechanism is operating locally active cytokine induces the heart to commit suicide at continuously, thus the unloading of high-pressure barore- the molecular level.16 In fact, tumor necrosis factor ␣ causes ceptors stimulate sympathetic activity, as well as the RAAS cachexia, anorexia, and inflammation. and Arginine Vasopressin (AVP).

Neurohormonal Activation GFR and Starling Forces Although kidney dysfunction at the present time is consid- The transcapillary hydrostatic pressure (⌬P) slowly decreases ered a general feature of congestive heart failure (CHF) it still along the capillary length both in health and heart failure. is undecided17 if it should be considered as a comorbidity or However, in CHF it is much higher than in normal patients a maladaptation that induces changes of fluid regulation and because of efferent arterial vasoconstriction. The transmural the renin-angiotensin-aldosterone system (RAAS). oncotic pressure (⌬␲) increases over the capillary length In CHF, significant changes occur in the cardiorenal axis, both in normal patients and patients with CHF. However, in which operates under the control of the RAAS (sodium re- CHF it also is higher because of the increase in FF. This taining, antidiuretic, vasoconstricting, and profibrotic), and situation is brought about by a disproportionate increase in of a group of peptides (atrial natriuretic peptide [ANP], brain efferent vasoconstriction that protects GFR. natriuretic peptide [BNP], and C-type natriuretic peptide Along the peritubular capillary, ⌬P is reduced more than [CNP]). ANP and BNP, released by myocardial cells of the in normal subjects. However, ⌬␲ is higher, thus the driving heart, and CNP, released by the endothelium, are natriuretic, force (⌬P Ϫ⌬␲) enhances proximal reabsorption of sodium diuretic, vasodilating, inhibitory for renin and aldosterone, and water. However, in CHF the changes in intrarenal hemo- and antifibrotic. In this context, ANP and BNP are seen as dynamics, the sympathetic stimulation, and the stimulation diuretic hormones secreted in response to stretch. ANP and of angiotensin II also may promote sodium reabsorption in BNP operate through guanylated cyclase A receptors, Henle’s loop.21 whereas CNP operates through a guanylate cyclase B recep- The afferent to efferent balance is shown in Figure 2, which tor. All of them are bound to a clearance receptor that me- gives a synopsis of RBF and GFR in treated and untreated tabolizes them through the neutral endopeptidase. Blockade heart failure patients.22 It should be added that patients with of neutral endopeptidase–receptor results in reduced GFR end-stage heart failure treated with angiotensin-converting 406 N.G. De Santo et al. enzyme (ACE) inhibitors have a normal renal reserve23 even in the presence of a reduction in GFR and RPF associated 40 40 % with enhanced FF (Fig 3). This also happens in mild CHF control (grade I NYHA) in which ACE inhibitors reinstate a renal 35 CHF reserve after infusion of amino acids.24 30 30 %

25 Renal Function 20 % and Survival in CHF 20 15 It is a common notion that in CHF survival depends on 10 % plasma sodium potassium and magnesium levels.25,26 Even 10 blood urea, considered an unreliable index of renal function, 5 can predict survival. Renal function is the most powerful predictor of mortality.27 A study in 1,906 patients with a 0 Renal reserve (ml/min) Renal reserve (%) creatinine clearance level less than 44 mL/min (calculated by means of the Cockroft and Gault equation) had a mortality Figure 3 Renal reserve in patients with end stage heart failure waiting risk of 2.85 in comparison with those patients with a creati- for heart transplantation. , control; □, CHF. Data from Frangiosa nine clearance of more than 76 mL/min (P Ͻ .001). The et al.23 study also showed that creatinine clearance is a stronger predictor of mortality than left ventricular ejection fraction or NYHA class and strongly correlated with N-terminal ANP.27 focus of the physician’s specialty). Since kidneys play an important role in heart disease and the heart plays a role in all patients with renal disease, cardiorenal interactions are be- Nephrologist- coming more and more important.21 Cardiologist Interaction References There is a general quest from patients with heart disease and 1. De Santo NG, Touwaide A: Edema in the Corpus Hippocraticum.AmJ from patients with kidney disease for a nephrologist-cardiol- Nephrol 19:155-158, 1999 28 ogist interaction. This also is stressed nicely by Packer : 2. Katz AM: Evolving concepts of the pathophysiology of heart failure, in As medicine is practiced in the 1990s the patients with Mann DL (ed): Heart Failure. Philadelphia, Saunders, 1904, pp 1-9 heart disease and renal disease (whether these disorders are 3. Arcieri JP: The circulation of the blood and Andrea Cesalpino of Arezzo. seen in the same patient or in different patients) are fre- New York, F.S. Vanni, 1945, p 47 4. Willius FA, Dry TJ: The heart and the circulation. Philadelphia, Saun- quently managed by physicians who are interested in only ders, 1948, pp 43-44 one of the two organ systems. Under the rare circumstances, 5. Starling EH: Physiological factors involved in the causation of dropsy. when the patient is visited by both types of specialists, the Lancet 1:1407-1419, 1986 physicians take frequently opposite point of view and make 6. Peters JP: Body water. Springfield, IL, Charles C. Thomas Publishers, therapeutic recommendations that are principally designed 1935 7. Stead EA Jr, Ebert RV: Shock syndrome produced by failure of the to preserve the function as a single organ system (that is the heart. Arch Intern Med 69:75-89, 1942 8. Warren JV, Stead EA Jr: Fluid dynamics in chronic congestive heart failure. Arch Intern Med 73:138-147, 1944 9. Anand IS: Pathogenesis of salt and water retention in the congestive heart failure syndrome, in Poole-Wilson PA, Colucci WS, Massie BM, et al (eds): Heart Failure. New York, Churchill Livingstone, 1997, pp 155-171 10. Andreoli TE: Edematous states: An overview. Kidney 51:S11-S15, 1997 (suppl 59) 11. Merrill AJ: Edema and decreased renal blood flow in patients with chronic congestive heart failure: Evidence of “forward failure” as the primary cause of edema. J Clin Invest 25:389-400, 1946 12. Aas K, Blegen E: The renal blood flow and the glomerular filtration rate in congestive heart failure and some other clinical conditions. Scand J Clin Invest 1:22-24, 1949 13. Ichikawa I, Pfeffer JM, Pfeffer MA, et al: Role of angiotensin II in the altered renal function of congestive heart failure. Circ Res 55:669-675, 1984 14. Kircheim H, Ehmke H, Hackenthal E, et al: Autoregulation of renal blood flow, glomerular filtration rate and renin release in conscious dogs. Am J Cardiol 410:411-449, 1987 15. Andreoli TE: Pathogenesis of renal sodium retention in congestive heart Figure 2 Afferent to efferent in different groups of patients with end failure. Miner Electrolyte Metab 25:11-20, 1999 stage heart failure (HF), also given ACE inhibitors (ACEI). Modified 16. Packer M: Is tumor necrosis factor an important neurohormonal mech- from Leier and Boudoulas.22 anism in chronic heart failure? Circulation 39:1379-1382, 1995 Kidney disease in CHF 407

17. Burnett JC Jr, Costello-Boerrigter L, Boerrigter G: Alteration of the kidney 23. Frangiosa A, Spitali L, Molino D, et al: Renal reserve is normal in in heart failure. The cardiorenal axis in the regulation of sodium homeosta- patients with dilative cardiomyopathy waiting for heart transplanta- sis, in Mann DL (ed): Heart Failure. Philadelphia, Saunders, 2004 tion. Miner Electrolyte Metab 25:24-27, 1999 18. Lee SC, Stevens TL, Sandberg SM, et al: The potential of BNP as a 24. Magri P, Rao MA, Cangianiello S, et al: Circulation 98:2849-2854, biomarker for NYHA class during the outpatients treatment of heart 1998 failure. J Card Fail 8:149-154, 2002 25. Leier CV, Del Cas L, Metra M: Clinical relevance and management of 19. Pitt B, Zannad F, Remme WJ, et al: The effect of spironolactone on the major electrolyte abnormalities in heart failure: Hyponatremia, hy- morbidity and mortality in patients with severe heart failure. Random- pokalemia and hypomagnesemia. Am Heart J 128:364-374, 1994 ized Aldactone Evaluation Study Investigators. N Engl J Med 341:709- 26. Parameshawar J, Keega J, Sparrow J, et al: Predictors of prognosis in 717, 1999 20. Harris P: Congestive cardiac failure. Central role of arterial blood pres- severe heart failure. Br Heart J 74:341-342, 1993 sure. Br Heart J 58:190-203, 1987 27. Hillege HL, Girbes ARJ, de Kam PJ, et al: Renal function, neurohor- 21. Harris P: Role of arterial blood pressure in oedema of heart disease. monal activation and survival in patients with chronic heart failure. Lancet 1:1036-1038, 1988 Circulation 102:203-210, 2000 22. Leier CV, Boudoulas H: Cardiorenal disease and disorders. Houston, 28. Packer M: Foreword, in Leier CV, Boudoulas H (eds): Cardiorenal Diseases Futura Publishing Company, 1992 and Disorders. Houston, Futura Publishing Company, 1992, p IV