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We are pleased to present our manuscript entitled “Incidence and types of Cardiorenal

Syndrome in Aswan University Hospital” as original article for presentation in Aswan

University Medical Journal.

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 Incidence and types of Cardiorenal Syndrome in

Aswan University Hospital

Omima Mohamed Aly1, Ramadan Ghaleb Mohamed2, Mohamed Tantawiey1*, Mohammed

Zain El-Din Hafiz3

1 Internal medicine department, Faculty of Medicine, Aswan University, Egypt
2 Cardiology department, Faculty of Medicine, Aswan University, Egypt
3 Internal Medicine department, Faculty of Medicine – Assiut University, Egypt

* Corresponding Author: Mohamed Tantawiey

Telephone number:01111224624

E-mail: mtantawiey@gmail.com

Abstract

Background; CRS and it's classification to 5 types according to the different diseases Which

effect on kidneys and heart with acute or chronic types and using broad spectrum from

laboratories and radiological investigations , early detection of the type is a fundamental goal

for the prevention of congestive heart failure in high-risk patients and deterioration of kidney

functions tested , Aim and objectives; was to identify the different types & clinical

evaluation of cardiorenal syndrome presented in Aswan university hospitals. Subjects and

methods; Cross-sectional study admitted to Internal Medicine& cardiology departments at

Aswan university hospital. The calculated sample size was obtained using simple random

sample of the patients. Results: Heart failure and renal failure related to each other in

chronicity result in different types of CR. Conclusion; ECG and kidney function test are a

quick bedside test and a non-invasive reliable technique for the assessment of Generalized

edema with decline in heart and kidney functions.

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Keywords: chest pain, AKI: dyspnea, dialysis, generalized edema

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Introduction

It is estimated that up to 50% of patients with chronic heart failure (HF) develop renal

dysfunction and cardiorenal syndrome (CRS), a complication associated with increased

mortality. However, the prevalence and clinical impact of renal dysfunction in hypertrophic

cardiomyopathy is unknown. (1)

CRS is defined as any acute or chronic problem in the heart or kidneys that could result in an

acute or chronic problem of the other. (2) CRS divided into 2 major groups, cardiorenal and

renocardiac syndromes, based on the primum movements of the disease process. This was

further grouped into 5 subtypes based on disease acuity and sequential organ: Type 1: a sharp

decline in cardiac function that results in an acute decrease in renal function, type 2: chronic

cardiac dysfunction that results in a sustained reduction in renal function, type 3: a sharp

decline in renal function that results in an acute reduction in cardiac function, type 4: a

chronic decline in kidney function that results in chronic cardiac dysfunction and type 5:

systemic diseases that result in both cardiac and renal dysfunction. (3,4)

The overall prognosis is poor. There are multiple mortality and readmission predictor

calculators available to predict the individual patient’s prognosis further. They use multiple

variables to predict in-hospital mortality and readmission rate, including ECG, the blood urea

nitrogen (BUN), systolic blood pressure (BP), serum creatinine, Pelvi abdominal us and

echocardiography.

The aim of this study is to identify the different types & clinical evaluation of cardiorenal

syndrome presented in Aswan university hospitals.

Patients and Methods

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This is a cross-sectional study was conducted in Internal Medicine& cardiology departments

at Aswan university hospital. We included 100 participants with the following inclusion

criteria: primary diagnosis, co-morbid diseases particularly diabetes mellitus, hypertension,

chronic kidney disease (CKD), myocardial infarction, coronary revascularization, chronic

obstructive pulmonary disease (COPD) and hemodynamic parameters (systolic & diastolic BP

& heart rate).

We performed the following investigations to the included participants: 1) Serum creatinine

and blood urea, 2) serum sodium, 3) potassium, 4) serum calcium, 5) phosphorus, 6) uric acid,

7) complete blood count, 8) pelvic abdominal Us and 9) transthoracic echocardiography.

Patients were classified according to the five types of CRS. Moreover, heart failure was

classified into mild, moderate, or severe. (5) While acute kidney injury was classified into 3

stages of severity based on serum creatinine (sCr) and urine output criteria into Stage 1,2 or 3,

as proposed by the Acute Kidney Injury Network (AKIN) criteria (6). Chronic kidney disease

(CKD) was diagnosed according to K-DOQI guidelines (7). Renal functions were evaluated

by the estimated glomerular filtration rate (GFR).

Statistical Analysis:

Data were summarized in mean ± SD for quantitative data and frequencies for qualitative

data. A two-sided P-value of < 0.05 was considered statistically significant. We used SPSS 25

software for data analyses.

Ethical consideration:

The study Protocol was submitted for approval from ethics committee and institutional review

board of Aswan faculty of Medicine.

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Results

We included 100 participants, with average age 58.73 ± 14.81. It was found that 54.0% aged

50-70 years, while 23.0% of them aged more than or equal 70 years. Half of the studied

patients were male (50.0%). The most common chronic diseases were hypertension (74.0%),

and diabetes mellitus (63.0%), while only 15.0% of them suffering from COPD (Table 1).

The classification of patient according to CRS types reported in (Table 3).

There was no significant relation between type of CRS and age and gender (P= 0.265 &

0.062). white, type of CRS was statistically significant in relation to CKD (P= 0.011*), HD

(P= 0.004*), and COPD (P= 0.034*). While there were no statistically significant relations

with DM (P= 0.643), or IHD (P= 0.625).

It was found that there was a statistically significant relation of type of CRS with Pelvi-

abdominal radiology (P= 0.000*), however, there was no statistically significant relation with

ECHO findings (P= 0.198).

Discussion

Cardiorenal syndrome (CRS) lacked a universally accepted definition for long, and numerous

related key questions yet remain unanswered. Clinical guidelines have classically treated

cardiac and renal failure separately, but the characteristics of CRS should be elucidated more

comprehensively to enhance the integrative clinical management of the syndrome (9)

This study shows that more than one-half of the studied patients (54.0%) aged 50-70 years,

while 23.0% of them aged more than or equal 70 years. The mean age of the patients was

58.73 ± 14.81. Regarding to gender, half of the studied patients were male (50.0%).

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In his study Abdullah et al., (10) showed that the incidence of CRS among 61-70 years was

18%, 31-40 was 13%, 71- 80 years was 8% and more than 80 years was 4% Calculated mean

age is 55.3±12.8 years. While Reddy et al., (11) included 106 of them, 69 (43.7%) were 60–

80 years old, 65 (41.1%) were 40–60 years old, 16 (10.1%) were ≥80 years old, and eight

(5.1%) were 20–40 years old.

This study shows that according to general conditions of the studied patients. The most

common chronic diseases were HTN (74.0%), and diabetes mellitus (63.0%) and CKD were

40%, while only 15.0% of them suffering from COPD.

In agreement with our results Abdullah et al., (10) showed that the most common risk factor

was HTN (75%) followed by diabetes (44%), smoking (35%), dyslipidaemia (30%) and

Alcohol (14%). Also Hu et al., (12) showed that 71.30% has HTN, 42.70% with diabetes,

24.7% patients were with a history of chronic kidney disease and 9.80% with COPD. H. R.

Shah et al., (13) showed that among the study population, 39 (78%) patients were

hypertensive and 32 (64%) were diabetic. Whereas 25 (50%) had underlying chronic kidney

disease, 24 (48%) patients had CAD and 22 (44%) had dyslipidaemia.

According to type of CRS, it was found that only 10% of them were type I, 33.0% of them

were type II, 25.0% were type III, 19.0% were type IV, and only 13.0% of them were type V.

H. R. Shah et al., (13) showed that out of 50 patients enrolled in study, 23 (46%) subjects

presented with type I CRS, 11 (22%) subjects with type II CRS, 13 (26%) subjects with type

IV CRS and 3 (6%) subjects with type 5 CRS, no individual came under the category of type

3 CRS. While Gigante et al., (14) results showed that 61 patients had clinical signs

compatible with a diagnosis of CRS type I (32.1%); 30 patients had CRS type II (15.8%); 15

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patients had CRS type III (7.9%); 11 patients had CRS type IV (5.8%), and 73 patients had

CRS type V (38.4%). CRS was more common in males (68.9% of patients).

It was found that there were statistically significant relations of type of CRS with CKD (P=

0.011*), with HD (P= 0.004*), and with COPD (P= 0.034*). While there were no statistically

significant relations with DM (P= 0.643), and with IHD (P= 0.625), while there was no

statistically significant relation with other chronic disease. Also, there were no statistically

significant relations of ejection fraction with Pelvi-abdominal (P= 0.782), and with ECHO

parameters (P= 0.064).

In agreement to our results Gigante et al., (14)showed that diabetes mellitus (p = 0.45), HTN

(p = 0.27), ischemic heart disease (p = 0.1) and COPD (p = 0.21) are not significant risk

factors for the onset of CRS. Also, H. R. Shah et al., (13) showed that the association of co-

morbidities (HTN, DM, COPD and CAD) with outcome were found to be statistically

insignificant.

On the other hand Reddy et al., (11)showed that there is a significant association between

CRS and risk factors, such as DM (P = 0.030), COPD (P = 0.016), and CKD (P > 0.001) with

CRS.

There was a statistically significant relation of type of CRS with Pelvi-abdominal (P=

0.000*), while there was no statistically significant relation with ECHO findings (P= 0.198).

Mavrakanas et al., (15) showed that echocardiographic parameters were independently

associated with the development of the CRS. Also, Reddy et al., (11) showed that according

to Echocardiography at 180 days, 38 patients was HFpEF (EF >50%), 39 patients was

HFmrEF (EF 41%-49%) and 70 patients was HFrEF (EF <40%).

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Limitations

The present study has some limitations, sample size is one of them, as our sample was

comparatively less. Future studies with larger sample size and more comprehensive and

longer follow-up are required to validate the findings. In addition, the study was conducted in

a tertiary care hospital in a city. Thus, the findings cannot be extrapolated to the general

population, including rural citizens. Nevertheless, the present study provides a basis for future

studies to study the subtypes of CRS and their individual pathophysiology.

Conclusion:

Current study suggests that types of CRS is related to chronic diseases, CRS is associated

with CKD, HD, and COPD. Moreover, to diagnosis CRS, and treat it early are very important

to decrease drawbacks and improve the prognosis.

Funding Sources: This research received no grant from any funding agency in the public,

commercial or not-for-profit sectors.

Conflict of Interest: The Authors declare that there is no conflict of interest

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Table 1: Personal data of the studied patients

No. (%)
Age: (years) Mean ± SD 58.73 ± 14.81
< 50 23 (23%)
50 - 70 54 (54%)
> 70 23 (23%)
Gender: Male 50 (50%)
Female 50 (50%)
General condition DM 63 (63%)
HTN 74 (74%)
CKD 40 (40%)
IHD 30 (30%)
HD 19 (19%)
COPD 15 (15%)
Type of CRS Type I 10
Type II 33
Type III 25
Type IV 19
Type V 13
Table 2: Relation between type of CRS and personal data
Type of CRS
Personal data Type I & II Type III & IV Type V P-value
No. % No. % No. %
Age: (years)
< 50 7 16.3 10 22.7 6 46.2
0.265
50 - 70 26 60.5 23 52.3 5 38.5
> 70 10 23.3 11 25.0 2 15.4
Gender:
Male 27 62.8 19 43.2 4 30.8 0.062
Female 16 37.2 25 56.8 9 69.2

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Table 3: Relation between type of CRS and general condition
Type of CRS
General
Type I & II Type III & IV Type V P-value
condition
No. % No. % No. %
DM 29 67.4 27 61.4 7 53.8 0.643
HTN 30 69.8 34 77.3 10 76.9 0.704
CKD 10 23.3 24 54.5 6 46.2 0.011*
IHD 15 34.9 12 27.3 3 23.1 0.625
HD 14 32.6 2 4.5 3 23.1 0.004*
COPD 4 9.3 6 13.6 5 38.5 0.034*
Table 4: Relation between type of CRS and radiology
Type of CRS
Radiology Type I & II Type III&IV Type V P-value
No. % No. % No. %
Pelvi-abdominal:
Normal 24 55.8 5 11.4 0 0.0 0.000*
Bilateral G I nephropathy 16 37.2 17 38.6 7 53.8 0.546
Bilateral G II nephropathy 2 4.7 10 22.7 5 38.5 0.007*
Bilateral G III nephropathy 1 2.3 12 27.3 1 7.7 0.003*
ECHO:
Normal 10 23.3 14 31.8 1 7.7
DDG 10 23.3 13 29.5 6 46.2
MR 21 48.8 23 52.3 12 92.3 0.198
TR 20 46.5 20 45.5 10 76.9
Picture of IHD 10 23.3 3 6.8 0 0.0

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