Cardiorenal Syndrome Type II with Heart Failure with Preserved Ejection Fraction

Cardiorenal syndrome type 2 (CRS2) is characterized by chronic abnormalities in cardiac function leading to kidney injury or dysfunction. The incidence of heart failure with preserved ejection fraction (HFPEF) is reported to include about 50% of the general heart failure population, while the prevalence of HFPEF is still increasing over the last years when compared to the prevalence of heart failure with reduced ejection fraction. Its prevalence is higher in the elderly especially in females; in a recent study of HFPEF, all patients were aged > 80 years, with a mean age of 87. This is Mr A.P, aged 84, referred to the emergency room by his attending physician for a flare-up of acute renal failure on a chronic basis and cardiopulmonary decompensation. His background: in 2020, chronic kidney failure at stage IV on probable nephroangiosclerosis with a baseline serum creatinine at 183 μmol/L or a glomerular filtration rate (GFR) according to Chronic Kidney Disease-epidemiology (CKD-EPI) at 27 ml/min in 2020, proteinuria at 0.36 g/24H, no hematuria. Clinical examination found a weight gain of 4 kg with a usual weight of 68 kg, BMI: 21.46 kg/m2. A BP: 89/52mmHg, Pulse: 65 b/min, saturation at 90% AA, it has three FRIED criteria of fragility (walking speed, reduction in muscular strength and involuntary weight loss over one year); edema of the lower limbs, respiratory distress with bilateral pleurisy. His electrocardiogram was unchanged, Troponin: 120 pg/ml, BNP: 919 ng/l; serum creatinine: 316 μmol/L, serum potassium: 5.8 mmol/L, proteinuria at 0.38 g/24hours, hematuria at 12 hties/mm3. Transthoracic ultrasound shows a congestive heart, IVC: 26 mm, LV dysfunction, no hypokinesia, ejection fraction (EF) at 50%, dilated OG and CD. His usual treatment is Seretide 250, 2 doses/day, PREVISCAN 2 mg/day, ENTRESTO 24/26mg, 2 times/day, FUROSEMIDE 125 mg/day, Allopurinol 100 mg/day, SERESTA 5 mg/day at bedtime and INEXIUM 40 mg/day. The emergency action was the cessation of ENTRESTO, oxygenotherapy, increase of FUROSEMIDE to 1 g IVSE/24H. The evolution is marked by the increase in acute renal failure with a Creatinine level of 400 μmol/L, an oliguria of 300 ml, a uremia of 60 mmol/L leading to extra-renal purification with the prescription of isolated daily ultrafiltrations for a week. Then dialytic frequencies were reduced to two per week in the face of clinical improvement marked by his oxygen withdrawal, stabilization of his renal function, regression of excess weight from 68 kg to 58 kg with reduction in BNP to 400 ng/l compared to 2000 ng/l. However, the patient remains dependent on dialysis and his loss of autonomy has increased in connection with a fracture of the neck of the femur on his right hip prosthesis and pulmonary embolism reinforcing his fragility. The coexistence of renal impairment in heart failure with preserved ejection fraction (CRS type 2 and 4) is common especially in older females with hypertension and/or diabetes. The management of this syndrome requires cardio-nephrological collaboration and characterization of patients and their prognosis.