Abstract

Cardiorenal syndrome in patients with ischemic chronic heart failure remains one of the most challenging problems in clinical cardiology and nephrology. Its significance is determined by the reciprocal interaction between cardiac and renal dysfunction, which increases the risk of hospitalization, worsens tolerance to evidence-based therapy and limits the achievement of target doses of prognostically important drugs. The aim of this review was to analyze current evidence on the diagnosis and treatment of cardiorenal syndrome in patients with ischemic chronic heart failure, focusing on publications from the last five years. Literature was searched in PubMed, Scopus, Web of Science, Cochrane Library, eLibrary, CyberLeninka and the Russian Science Citation Index for 2021-2026. Clinical guidelines, consensus documents, systematic reviews, meta-analyses, major randomized trials and Russian-language publications on chronic heart failure, chronic kidney disease, congestion assessment, renal biomarkers and contemporary therapy were included. Current evidence indicates that the diagnosis of cardiorenal syndrome should not rely only on serum creatinine and estimated glomerular filtration rate. A more justified approach combines albuminuria, natriuretic peptides, electrolytes, clinical and ultrasound signs of venous congestion, and response to diuretic therapy. Treatment should include individualized decongestion, preservation of guideline-directed heart failure therapy, use of sodium-glucose cotransporter 2 inhibitors and regular monitoring of renal function. Early detection of subclinical kidney injury, differentiation between functional creatinine rise and true kidney damage, and selection of treatment strategy in diuretic resistance remain insufficiently resolved.
 

Keywords

Cardio-Renal Syndrome Heart Failure Myocardial Ischemia Renal Insufficiency Chronic Diagnosis Therapeutics Sodium-glucose cotransporter 2 inhibitors.

Full Text

Download Article as PDF

Full article in PDF format

References

  1. Galyavich AS, Tereshchenko SN, Uskach TM, Ageev FT, Aronov DM, Arutyunov GP, et al. Khronicheskaya serdechnaya nedostatochnost'. Klinicheskie rekomendatsii 2024 [Chronic heart failure. Clinical guidelines 2024]. Rossiyskiy kardiologicheskiy zhurnal. 2024;29(11):251-349. (In Russ.) https://doi.org/10.15829/1560-4071-2024-6162.
  2. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021;42(36):3599-3726. https://doi.org/10.1093/eurheartj/ehab368
  3. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, et al. 2023 Focused Update of the 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2023;44(37):3627-39. https://doi.org/10.1093/eurheartj/ehad195
  4. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, et al. 2022 AHA/ACC/HFSA Guideline for the management of heart failure. Circulation. 2022;145(18):e895-e1032. https://doi.org/10.1161/CIR.0000000000001063
  5. Kidney Disease: Improving Global Outcomes CKD Work Group. KDIGO 2024 Clinical Practice Guideline for the evaluation and management of chronic kidney disease. Kidney Int. 2024;105(4S):S117-S314. https://doi.org/10.1016/j.kint.2023.10.018
  6. Vrints C, Andreotti F, Koskinas KC, Rossello X, Adamo M, Ainslie J, et al. 2024 ESC Guidelines for the management of chronic coronary syndromes. Eur Heart J. 2024;45(36):3415-537. https://doi.org/10.1093/eurheartj/ehae177
  7. Polyakov DS, Fomin IV, Belenkov YuN, Mareev VYu, Ageev FT, Artemyeva EG, et al. Khronicheskaya serdechnaya nedostatochnost' v Rossiyskoy Federatsii: chto izmenilos' za 20 let nablyudeniya? Rezul'taty issledovaniya EPOKHA-KhSN [Chronic heart failure in the Russian Federation: what has changed over 20 years of follow-up? Results of the EPOCH-CHF study]. Kardiologiya. 2021;61(4):4-14. (In Russ.) https://doi.org/10.18087/cardio.2021.4.n1628.
  8. Mezhonov EM, Reytblat OM, Vyalkina YuA, Ayrapetyan AA, Lazareva NV, Ageev FT, et al. Khronicheskaya bolezn' pochek i khronicheskaya serdechnaya nedostatochnost': vliyanie na prognoz i vybor patogeneticheskoy terapii [Chronic kidney disease and chronic heart failure: impact on prognosis and choice of pathogenetic therapy]. Terapevticheskiy arkhiv. 2024;96(7):666-74. (In Russ.) https://doi.org/10.26442/00403660.2024.07.202781.
  9. Zhao BR, Hu XR, Wang WD, Zhang Q, Li Y, Zhou Y. Cardiorenal syndrome: clinical diagnosis, molecular mechanisms and therapeutic strategies. Acta Pharmacol Sin. 2025;46(6):1539-55. https://doi.org/10.1038/s41401-025-01476-z
  10. Stefanou E, Tountas C, Ioannidis E, Kole C. Biomarkers in cardiorenal syndrome, a potential use in precision medicine. J Nephrol. 2024;37(8):2127-38. https://doi.org/10.1007/s40620-024-02047-x
  11. Goffredo G, Barone R, Guarino M, Cappetta D, Paolisso P, Rizzo S, et al. Biomarkers in cardiorenal syndrome. J Clin Med. 2021;10(15):3433. https://doi.org/10.3390/jcm10153433
  12. Levitskaya ES, Batyushin MM, Zakusilov DI, Batyushina AM. Kardiorenal'nyy kontinuum: kliniko-patogeneticheskie vzaimosvyazi mezhdu khronicheskoy serdechnoy nedostatochnost'yu s sokhranennoy fraktsiey vybrosa i disfunktsiey kanal'tsev pochek [Cardiorenal continuum: clinical and pathogenetic relationships between heart failure with preserved ejection fraction and renal tubular dysfunction]. Kardiovaskulyarnaya terapiya i profilaktika. 2024;23(9):120-30. (In Russ.) https://doi.org/10.15829/1728-8800-2024-4063
  13. Drapkina OM, Kobalava ZhD, Shestakova MV, Bobkova IN, Efremovtseva MA, Villevalde SV, et al. Serdechno-sosudistyy risk i khronicheskaya bolezn' pochek: strategii kardionefroprotektsii. Mezhdistsiplinarnyy konsensus [Cardiovascular risk and chronic kidney disease: strategies for cardionephroprotection. Interdisciplinary consensus]. Kardiovaskulyarnaya terapiya i profilaktika. 2025;24(6):4466. (In Russ.) https://doi.org/10.15829/1728-8800-2025-4466
  14. Voors AA, Angermann CE, Teerlink JR, Collins SP, Kosiborod M, Biegus J, et al. The SGLT2 inhibitor empagliflozin in patients hospitalized for acute heart failure: a multinational randomized trial. Nat Med. 2022;28(3):568-74. https://doi.org/10.1038/s41591-021-01659-1
  15. Mullens W, Dauw J, Martens P, Verbrugge FH, Nijst P, Meekers E, et al. Acetazolamide in acute decompensated heart failure with volume overload. N Engl J Med. 2022;387(13):1185-95. https://doi.org/10.1056/NEJMoa2203094
  16. Mebazaa A, Davison B, Chioncel O, Cohen-Solal A, Diaz R, Filippatos G, et al. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure: the STRONG-HF trial. Lancet. 2022;400(10367):1938-52. https://doi.org/10.1016/S0140-6736(22)02076-1
  17. Solomon SD, McMurray JJV, Claggett B, de Boer RA, DeMets D, Hernandez AF, et al. Dapagliflozin in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2022;387(12):1089-98. https://doi.org/10.1056/NEJMoa2206286
  18. Anker SD, Butler J, Filippatos G, Ferreira JP, Bocchi E, Böhm M, et al. Empagliflozin in heart failure with a preserved ejection fraction. N Engl J Med. 2021;385(16):1451-61. https://doi.org/10.1056/NEJMoa2107038
  19. Herrington WG, Staplin N, Wanner C, Green JB, Hauske SJ, Emberson JR, et al. Empagliflozin in patients with chronic kidney disease. N Engl J Med. 2023;388(2):117-27. https://doi.org/10.1056/NEJMoa2204233
  20. Solomon SD, McMurray JJV, Vaduganathan M, Claggett BL, Jhund PS, Desai AS, et al. Finerenone in heart failure with mildly reduced or preserved ejection fraction. N Engl J Med. 2024;391(16):1475-85. https://doi.org/10.1056/NEJMoa2407107
  21. Campos-Sáenz de Santamaría A, Albines Fiestas ZS, Crespo-Aznarez S, Esterellas-Sánchez LK, Sánchez-Marteles M, Garcés-Horna V, et al. VExUS protocol along cardiorenal syndrome: an updated review. J Clin Med. 2025;14(4):1334. https://doi.org/10.3390/jcm14041334
  22. Wu L, Lam CSP, Ho JE. Diuretic treatment in heart failure: a practical guide for clinicians. J Clin Med. 2024;13(15):4470. https://doi.org/10.3390/jcm13154470
  23. Zhu Y, Li Y, Wang S, Chen X. Chronic cardiorenal syndrome: cardio-renal protective effect of sodium-glucose cotransporter 2 inhibitors. Front Pharmacol. 2025;16:1488892. https://doi.org/10.3389/fphar.2025.1488892
  24. Adamo M, Metra M, Chioncel O, Mebazaa A, Diaz R, Davison B, et al. NT-proBNP and high intensity care for acute heart failure: the STRONG-HF trial. Eur Heart J. 2023;44(31):2947-62. https://doi.org/10.1093/eurheartj/ehad335
  25. Mc Causland FR, Claggett BL, Vaduganathan M, Desai AS, Jhund PS, de Boer RA, et al. Dapagliflozin and kidney outcomes in patients with heart failure with mildly reduced or preserved ejection fraction: a prespecified analysis of the DELIVER randomized clinical trial. JAMA Cardiol. 2023;8(1):56-65. https://doi.org/10.1001/jamacardio.2022.4010
  26. Packer M, Anker SD, Butler J, Filippatos G, Pocock SJ, Carson P, et al. Cardiovascular and renal outcomes with empagliflozin in heart failure. N Engl J Med. 2020;383(15):1413-24. https://doi.org/10.1056/NEJMoa2022190