Table 3.
Therapeutic approaches for cardiorenal syndrome.
| Drugs | Mechanism of Action | Side Effects/Contraindications | Clinical Use |
|---|---|---|---|
| Beta Blockers | Beta adrenergic Receptor Antagonism | Bradycardia, AVB; asthma/bronchospasm, hypotension, unstable HF. |
Predominantly in chronic HF with reduced and mid-range ejection fraction without cardiogenic shock to improve morbidity and mortality. (CRS 2-4) |
| ACEi/ARB | Inhibition of ACE or AT1 receptor antagonism | Hyperkalemia, Renal failure, Hypotension, Idiopathic angio-oedema; Pregnancy, breastfeeding |
Predominantly in chronic HF with reduced and mid-range ejection fraction without cardiogenic Shock to improve morbidity and mortality. (CRS 2-4) |
| ARNI | AT1/Neprilysin Inhibitor | Hyperkalemia, Renal Failure, Hypotension |
Predominantly in chronic heart failure with reduced and mid-range ejection fraction without cardiogenic Shock to improve morbidity and mortality. (CRS 2-4) |
| MRA | Antagonism of mineralocorticoid receptor | Hyperkalemia, Renal Failure, Hypotension |
Predominantly in chronic heart failure with reduced and mid-range ejection fraction without cardiogenic Shock to improve morbidity and mortality. (CRS 2-4) |
| SGLT2i | Antagonism of the cotransporter SLC5A2 in the PT1 | Type 1 diabetes mellitus, Acute Metabolic Acidosis | Predominantly in chronic heart failure with reduced, ejection fraction without cardiogenic Shock to improve morbidity and mortality. (CRS 2-4) |
| Diuretics | NKCC, NCC, CA Antagonism | Hypotension, Hypokalemia, Hypo-/Hypercalcemia, Hyponatremia, Hypochloremia, Hypovolemia, Metabolic Alkalosis, Diuretic Resistance. |
In Acute and Chronic heart failure with reduced, mid-range and preserved ejection fraction to improve symptoms and volume overload. (CRS 1-2-4) In acute and chronic kidney disease to maintain an effective diuresis (CRS 1-3-4) |
| Vaptans | Selective Antagonism of V2 Receptor | Pollakiuria, Nycturia, polydipsia, Hypernatremia, Signs of Liver Injury. |
Advanced Heart Failure with hyponatremia (CRS 1-3) |
| Inotropic Drugs | Beta receptor agonism, Calcium sensitizers | Supraventricular and ventricular arrhythmias, increased myocardial oxygen consumption due to increased myocardial work, hypotension. |
Acute heart failure and cardiogenic Shock (CRS 1) |
| UF/CRRT | Convection/Diffusion fluid and solute removal for the improvement of volume, osmolite and water balance | Hypotension, hypovolemia, reduced pre-load, thrombus formation, bleedings, vascular complications of the access site |
Acute heart failure and cardiogenic shock in patients with volume overload in the absence of proper diuretic response (CRS 1-3) |
ACE, Angiotensin Converting Enzyme; ARB, Angiotensin Receptor Blockers; ARNI, Angiotensin Receptor/Neprilysin Inhibitor; AVB, Atrioventricular Blocks; AT 1, Angiotensin Receptor 1; CA, Carbonic Anhydrase; CRRT, Continuous Renal Replacement Therapy; CRS, Cardio-renal Syndrome; HF, Heart Failure; MRA, Mineral corticoid Receptor Antagonists; NCC, Sodium Chloride Co-transporters; NKCC, Sodium Potassium Chloride Cotransporters; PT1, Proximal Tubule 1; SCLA5A2, Solute Carrier Family 5 Member 2; SGLT2, Sodium Glucose Co-Transporter 2; UF, Ultrafiltration.