Cardiorenal Syndrome: the bidirectional heart-kidney axis

Authors

DOI:

https://doi.org/10.5380/avs.v30i3.99132

Keywords:

heart-kidney axis, cardiac injuries, kidney injuries

Abstract

Cardiorenal syndrome is configured as a set of disorders that affect the heart and/or kidneys, and induce a series of events that alter the entire pre-existing axis between the two systems. Accurate diagnosis and adequate monitoring of patients with cardiovascular and renal diseases have become increasingly frequent. Systems are increasingly interconnected, and paying attention to changes has become fundamental. The objective of this article is to characterize cardiorenal syndrome, highlighting its clinical, pathophysiological, diagnostic, and therapeutic management aspects. Dogs and cats are susceptible to kidney changes that alter blood flow, which can interfere with cardiac function, and the reverse may also occur, particularly if dogs/cats already have the organ affected by other diseases. Furthermore, a series of systemic events can end up interfering even more with the communication between the two systems. The monitoring and follow-up of cardiac and/or nephropathic patients are of fundamental importance in determining the best therapeutic management to be instituted, thereby avoiding complications and injuries to other organs, preventing aggravations to the patient's clinical condition, and reducing their life expectancy.

Author Biographies

Felipe Gaia de Sousa, Federal University of Minas Gerais

Federal University of Minas Gerais

Ruthnea Muzzi, Federal University of Lavras

Federal University of Lavras

Fabiana Silva Fádel Queiroz, Federal University of Minas Gerais

Federal University of Minas Gerais

Suzane Lilian Beier, Federal University of Minas Gerais

Federal University of Minas Gerais

Maira Oliveira Barreto, Vena Cardiologia Veterinária

Vena Cardiologia Veterinária

Myrian Kátia Iser Teixeira, Newton Paiva University Center

Centro Universitário Newton Paiva

References

Acierno MJ, Brown S, Coleman AE, et al. ACVIM consensus statement: Guidelines for the identification, evaluation, and management of systemic hypertension in dogs and cats. J Vet Intern Med, 32(6):1803-1822, 2018. https://doi.org/10.1111/jvim.15307.

Aronson D. Cardiorenal syndrome in acute decompensated heart failure. Expert Review of Cardiovascular Therapy, 10(2): 177-189, 2012. https://doi.org/10.1586/erc.12.2.

Borgarelli M, Haggström J. Canine degenerative myxomatous mitral valve disease: natural history, clinical presentation and therapy. Vet Clin North Am Small Anim Pract, 40(4):651-663, 2010. https://doi.org/10.1016/j.cvsm.2010.03.003.

Brložnik M, Pečjak A, Nemec Svete A, et al. Selected hematological, biochemical, and echocardiographic variables as predictors of survival in canine patients with myxomatous mitral valve disease and congestive heart failure. J Vet Cardiol, 46:18-29, 2023. https://doi.org/10.1016/j.jvc.2023.02.004.

Bussadori C. Tratado de Medicina Cardiovascular em cães e gatos. MedVet, São Paulo, 2024. 536 p. ISSN: 1415-2837.

Cheng CJ, Mandour AS, Yoshida T, et al. Changes in renin-angiotensin-aldosterone system during cardiac remodeling after mitral valvuloplasty in dogs. J Vet Intern Med, 36(2):397-405, 2022. https://doi.org/10.1111/jvim.16455.

Chetboul V, Bussadori C, Madron E. Clinical echocardiography of the dog and cat. Elsevier, 2015. 348 p. ISSN: 0065-9784.

Crosara S, Fidanzio F, Oricco S, et al. Association between echocardiographic indexes and urinary Neutrophil Gelatinase-Associated Lipocalin (uNGAL) in dogs with myxomatous mitral valve disease. Res Vet Sci, 171:105211, 2024. https://doi.org/10.1016/j.rvsc.2023.12.008.

Davis J, Rossi G, Cianciolo RE, et al. Early diagnosis of acute kidney injury subsequent to severe hypotension and fluid resuscitation in anaesthetized dogs. Vet Anaesth Analg, 49(4):344-353, 2022. https://doi.org/10.1016/j.vaa.2022.01.001.

Ferasin L, Ferasin H, Farminer J, et al. Diagnostic value of a point-of-care cardiac troponin-I assay (i-STAT®) for clinical application in canine and feline cardiology. J Vet Cardiol, 56:35-43, 2024. https://doi.org/10.1016/j.jvc.2024.07.006

Fox PR, Keene BW, Lamb K, et al. Long-term incidence and risk of noncardiovascular and all-cause mortality in apparently healthy cats and cats with preclinical hypertrophic cardiomyopathy. J Vet Intern Med, 33(6):2572-2586, 2019. https://doi.org/10.1111/jvim.15664.

Freitas GC, Veado JCC, Carregaro AB. Teste de avaliação de injúria renal precoce em cães e gatos. Semina: Ciências Agrárias, 35(1): 411-426, 2014. https://doi.org/10.5433/1679-0359.2014v35n1p411

Gal A, Burchell RK. Diabetes Mellitus and the Kidneys. Vet Clin North Am Small Anim Pract, 53(3):565-580, 2023. https://doi.org/10.1016/j.cvsm.2023.03.003.

Galizzi A, Bagardi M, Stranieri A, et al. Factors affecting the urinary aldosterone-to-creatinine ratio in healthy dogs and dogs with naturally occurring myxomatous mitral valve disease. BMC Vet Res, 17(1):15, 2021. https://doi.org/10.1186/s12917-021-02758-3.

Gavazza A, Marchegiani A, Guerriero L, et al. Updates on Laboratory Evaluation of Feline Cardiac Diseases. Vet Sci, 8(3):41, 2021. https://doi.org/10.3390/vetsci8030041.

Ghio S, Traversi E, Maestri R, et al. Sodium nitroprusside infusion in patients with advanced heart failure. Vascul Pharmacol, 156:107395, 2024. https://doi.org/10.1016/j.vph.2024.107395.

Giorgi ME, Mochel JP, Yuan L, et al. Retrospective evaluation of risk factors for development of kidney injury after parenteral furosemide treatment of left-sided congestive heart failure in dogs. J Vet Intern Med, 36(6):2042-2052, 2022. https://doi.org/10.1111/jvim.16512.

Gouni V, Chetboul V, Pouchelon JL, et al. Azotemia in cats with feline hypertrophic cardiomyopathy: prevalence and relationships with echocardiographic variables. J Vet Cardiol, 10(2):117-123, 2008. https://doi.org/10.1016/j.jvc.2008.02.002.

Gu YZ, Vlasakova K, Darbes J, et al. Urine kidney safety biomarkers improve understanding of indirect intra-renal injury potential in dogs with a drug-induced prerenal azotemia. Toxicology, 439:152462, 2020. https://doi.org/10.1016/j.tox.2020.152462.

Guyton AC, Hall JE. Guyton And Hall Textbook of Medical Physiology. Philadelphia: Elsevier, 2021. 1028 p. ISBN: 978-0-323-59712-8

Hanås S Holst, BS, Höglund K, et al. Effect of feline characteristics on plasma N-terminal prohormone B-type natriuretic peptide concentration and comparison of a point-of-care test and an ELISA test. J Vet Intern Med, 34(3):1187-1197, 2020. https://doi.org/10.1111/jvim.15785.

International Renal Interest Society. Iris Guidelines 2023. Disponível em: http://www.iris-kidney.com/guidelines/. Acesso em: 10 de out. 2024.

Ishizaka M, Yamamori Y, Hsu H.-H., et al. Study on the Effects of Angiotensin Receptor/Neprilysin Inhibitors on Renal Haemodynamics in Healthy Dogs. Int J Mol Sci, 25(11):6169, 2024. https://doi.org/10.3390/ijms25116169.

Iwasa N, Kumazawa R, Nomura S, et al. Prognostic value of serum cystatin C concentration in dogs with myxomatous mitral valve disease. J Vet Intern Med, 37(2):412-419, 2023. https://doi.org/10.1111/jvim.16444.

Jung H.-B., Kang M.-H., Park H.-M. Evaluation of serum neutrophil gelatinase–associated lipocalin as a novel biomarker of cardiorenal syndrome in dogs. J Vet Diagn Invest, 30(3):386–391, 2018. https://doi.org/10.1177/1040638718758430

Kanno N, Hori Y, Hidaka Y, et al. Plasma atrial natriuretic peptide and N-terminal pro B-type natriuretic peptide concentrations in dogs with right-sided congestive heart failure. J Vet Med Sci, 78(4):535-542, 2016. https://doi.org/10.1292/jvms.15-0631.

Keene BW, Atkins CE, Bonagura JD, et al. ACVIM consensus guidelines for the diagnosis and treatment of myxomatous mitral valve disease in dogs. J Vet Intern Med, 33(3):1127-1140, 2019. https://doi.org/10.1111/jvim.15426.

Kim YH, Kim JH, Park C. Evaluation of tissue Doppler ultrasonographic and strain imaging for assessment of myocardial dysfunction in dogs with type 1 diabetes mellitus. Am J Vet Res, 79(10):1035-1043, 2018. https://doi.org/10.2460/ajvr.79.10.1035.

Lalor SM, Connolly DJ, Elliott J, Syme HM. Plasma concentrations of natriuretic peptides in normal cats and normotensive and hypertensive cats with chronic kidney disease. J Vet Cardiol, 11:S71-9, 2009. https://doi.org/10.1016/j.jvc.2009.01.004

Langhorn R, Jessen LR, Kloster AS, et al. Cardiac troponin I in cats with compromised renal function. J Feline Med Surg, 21(10):985-991, 2018. https://doi.org/10.1177/1098612X18775948.

Langhorn R, Willesen JL, Tarnow I, et al. Evaluation of a high-sensitivity assay for measurement of canine and feline serum cardiac troponin I. Vet Clin Pathol, 42(4):490-498, 2013. https://doi.org/10.1111/vcp.12062.

Liu M, Koster LS, Fosgate GT, et al. Cardiovascular-renal axis disorder and acute-phase proteins in cats with congestive heart failure caused by primary cardiomyopathy. J Vet Intern, 34(3):1078-1090, 2020. https://doi.org/10.1111/jvim.15757.

Lombardo SF, Ferasin H, Ferasin L. Subcutaneous Furosemide Therapy for Chronic Management of Refractory Congestive Heart Failure in Dogs and Cats. Animals (Basel), 15(3):358, 2025. https://doi.org/10.3390/ani15030358.

Lopes SCC. Cardiorenal Syndrome: Therapeutical Challenge. Dissertação MSc. Escola Universitária Vasco Da Gama, Coimbra, 35p. 2016.

Luis Fuentes VL, Abbott J, Chetboul V, et al. ACVIM consensus statement guidelines for the classification, diagnosis, and management of cardiomyopathies in cats. J Vet Intern Med, 34(3):1062-1077, 2020. https://doi.org/10.1111/jvim.15878.

Martinelli E, Locatelli C, Bassis S, et al. Preliminary Investigation of Cardiovascular-Renal Disorders in Dogs with Chronic Mitral Valve Disease. J Vet Intern Med, 30(5):1612-1618, 2016. https://doi.org/10.1111/jvim.14524.

Martins ARC, Shih A. Fluidoterapia - Bases e Principais Indicações. In: Jericó MM, Neto JPA, Kogika MM, eds. Tratado de Medicina Interna de Cães e Gatos. Rio de Janeiro: Guanabara Koogan, 2015. p. 913-920. ISSN: 1415-3200.

Mikawa S, Nagakawa M, Ogi H, et al. Use of vertebral left atrial size for staging of dogs with myxomatous valve disease. J Vet Cardiol, 30:92-99, 2020. https://doi.org/10.1016/j.jvc.2020.01.001.

Mitani S, Yabuki A, Taniguchio K, et al. Association between the intrarenal renin-angiotensin system and renal injury in chronic kidney disease of dogs and cats. J Vet Med Sci, 75(2):127-133, 2013. https://doi.org/10.1292/jvms.12-0434.

Morita S, Mochizuki Y, Matsumoto I, et al. Use of amlodipine in the treatment of cats with systemic hypertension in Japan. J Vet Med Sci, 86(5):533-541, 2024. https://doi.org/10.1292/jvms.23-0355.

O’Neill KE, Labato MA, Court MH. The pharmacokinetics of intravenous fenoldopam in healthy, awake cats. J Vet Pharmacol Ther, 39(2):202-204, 2016. https://doi.org/10.1111/jvp.12222.

Oliveira MM, Furtado LLA, Abreu CB, et al. Síndrome cardiorrenal em cães: A busca por medidas de controle. Vet Zootec, 26:001-007, 2019. https://doi.org/10.5935/1678-5044.201900010.

Orvalho JS, Cowgill LD. Cardiorenal syndrome: diagnosis and management. Vet Clin North Am Small Anim Pract, 47(5):1083-1102, 2017. https://doi.org/10.1016/j.cvsm.2017.04.004.

Ostroski CJ, Drobatz KJ, Reineke EL. Retrospective evaluation of and risk factor analysis for presumed fluid overload in cats with urethral obstruction: 11 cases (2002–2012). J Vet Emerg Crit Care (San Antonio), 27(5):561-568, 2017. https://doi.org/10.1111/vec.12631

Oyama MA. Using Cardiac Biomarkers in Veterinary Practice. Clin Lab Med, 35(3):555-566, 2015. https://doi.org/10.1016/j.cll.2015.04.001.

Pelander L, Bach MBT, Ljungvall I, et al. Evaluation of cardiac troponin I as a predictor of death in critically ill cats. J Vet Intern Med, 37(2):403-411, 2023. https://doi.org/10.1111/jvim.16635.

Pelander L, Häggström J, Ley CJ, et al. Cardiac Troponin I and Amino-Terminal Pro B-Type Natriuretic Peptide in Dogs With Stable Chronic Kidney Disease. J Vet Intern Med, 31(3):805-813, 2017. https://doi.org/10.1111/jvim.14876.

Perondi F, Lippi I, Marchetti V, et al. How Ultrasound Can Be Useful for Staging Chronic Kidney Disease in Dogs: Ultrasound Findings in 855 Cases. Vet Sci, 7(4):147, 2020. https://doi.org/10.3390/vetsci7040147.

Pouchelon JL, Atkins CE, Bussadori C, et al. Cardiovascular–renal axis disorders in the domestic dog and cat: a veterinary consensus statement. J Small Anim Pract, 56(9):537-552, 2015. https://doi.org/10.1111/jsap.12409.

Rangaswami J, Bhalla V, Blair JEA, et al. Cardiorenal Syndrome: Classification, Pathophysiology, Diagnosis, and Treatment Strategies: A Scientific Statement From the American Heart Association. Circulation, 139(16):e840-e878, 2019. https://doi.org/10.1161/CIR.0000000000000674.

Reynolds BS, Chetboul V, Elliott J, et al. Long-term safety of dietary salt: A 5-year prospective randomized blinded and controlled study in healthy aged cats (PEANUT study). J Vet Intern Med, 38(1):285-299, 2024. https://doi.org/10.1111/jvim.16684.

Ronco C, Di Lullo L. Cardiorenal syndrome. Heart Fail Clin, 10(2):251-280, 2014. https://doi.org/10.1016/j.hfc.2013.11.007.

Ronco C, McCullough P, Anker SD, et al. Cardio-renal syndromes: report from the consensus conference of the acute dialysis quality initiative. Eur Heart J, 31(6):703-711, 2010. https://doi.org/10.1093/eurheartj/ehp557.

Sabbah HN, Zhang K, Gupta RC, et al. Effects of Angiotensin-Neprilysin Inhibition in Canines with Experimentally Induced Cardiorenal Syndrome. J Card Fail, 26(11):987-997, 2020. https://doi.org/10.1016/j.cardfail.2020.08.009

Santilli R, Sydney Moïse N, Pariaut R, Perego M. Eletrocardiografia de Cães e Gatos Diagnóstico de Arritmias. 2ª edição. MedVet, 2021. 376 p. ISSN: 0103-7370.

Segev G, Cortellini S, Foster JD, et al. International Renal Interest Society best practice consensus guidelines for the diagnosis and management of acute kidney injury in cats and dogs. Vet J, 305 (2024):106068. https://doi.org/10.1016/j.tvjl.2024.106068.

Sohn J, Yun S, Lee J, et al. Reestablishment of radiographic kidney size in Miniature Schnauzer dogs. J Vet Med Sci, 78(12):1805-1810, 2017. https://doi.org/10.1292/jvms.17-0275.

Sousa FG, Mendes ACR, Carvalho LP, et al. Clinical-Diagnostic and Therapeutic Advances in Feline Hypertrophic Cardiomyopathy. Vet Sci, 12(3):289, 2025. https://doi.org/10.3390/vetsci12030289.

Sousa FG, Oliveira BCG, Ferreira NS, et al. Hipertensão arterial sistêmica e as diretrizes para identificação, avaliação, controle e manejo hipertensivo em cães e gatos. Vet Zootec, 30(2023):1-23, 2023. https://doi.org/10.5935/1678-5044.202300010.

Sousa FG. Avaliação de efeitos cardiovasculares da angiotensina (1-7) após administração do peptídeo em formulação oral em felinos. Dissertação MSc em Ciência Animal. Escola de Veterinária, Universidade Federal de Minas Gerais, 137p. 2024.

Sousa FG, Queiroz FSF, Muzzi RAL, et al. Systemic Arterial Hypertension and Factors Associated with Blood Pressure Dysregulation in Companion Animals. Vet Sci, 12(5):453, 2025. https://doi.org/10.3390/vetsci12050453

Szczepankiewicz B, Paslawska U, Paslawski R, et al. The urine podocin/creatinine ratio as a novel biomarker of cardiorenal syndrome in dogs due to degenerative mitral valve disease. J Physiol Pharmacol, 70(2):249-257, 2019. https://doi.org/10.26402/jpp.2019.2.249.

Szczepankiewicz B, Pasławska U, Siwińska N, et al. Evaluation of the diagnostic value of the renal resistive index as a marker of the subclinical development of cardiorenal syndrome in MMVD dogs. J Renin Angiotensin Aldosterone Syst, 22(1):1470320321995082, 2021. https://doi.org/10.1177/1470320321995082.

Troia R, Sabetti MC, Crosara S, et al. Evaluation of urinary neutrophil gelatinase-associated lipocalin to detect renal tubular damage in dogs with stable myxomatous mitral valve disease. J Vet Intern Med, 36(6):2053-2062, 2022. https://doi.org/10.1111/jvim.16503.

Valente C, Guglielmini C, Domenech O, et al. Symmetric dimethylarginine in dogs with myxomatous mitral valve disease at various stages of disease severity. PLoS One, 15(9):e0238440, 2020. https://doi.org/10.1371/journal.pone.0238440.

Wess G. Screening for dilated cardiomyopathy in dogs. J Vet Cardiol, 40:51-68, 2022. https://doi.org/10.1016/j.jvc.2022.03.002.

Whitehouse WH, Thomason JD, Thompson-Butler DA, et al. A clinically utilized intravenous continuous rate infusion of diltiazem does not significantly decrease systolic function in healthy dogs. Am J Vet Res, 84(2):ajvr.22.09.0158, 2023. https://doi.org/10.2460/ajvr.22.09.0158.

Wrześniewska K, Madany J, Tobolski D, et al. A Pilot Study of the Role of Selected Biomarkers of Kidney Injury in Dogs with Dilated Cardiomyopathy. Animals (Basel), 14(9):1305, 2024. https://doi.org/10.3390/ani14091305.

Yun H, Koo Y, Yun T, et al. Evaluation of progression of chronic kidney disease in dogs with myxomatous mitral valve disease. Front Vet Sci, 10:1200653, 2023. https://doi.org/10.3389/fvets.2023.1200653.

Published

2025-09-09

How to Cite

Gaia de Sousa, F., Muzzi, R., Queiroz, F., Beier, S., Barreto, M., & Teixeira, M. (2025). Cardiorenal Syndrome: the bidirectional heart-kidney axis. Archives of Veterinary Science, 30(3). https://doi.org/10.5380/avs.v30i3.99132