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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The association between cardiac and renal disease has been an area of growing interest in recent years&#46; The interactions between these organs play an important role in control of blood pressure&#44; renal sodium and water excretion&#44; arterial perfusion and tissue oxygenation&#44; and&#44; most importantly&#44; extracellular fluid balance&#44; including intravascular volume&#46; It is therefore not surprising that&#44; when one organ becomes dysfunctional&#44; the other may be affected as well&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Heart failure &#40;HF&#41; interacts with renal disease via several pathophysiological pathways in both acute and chronic settings&#46; The expression &#8216;cardiorenal syndrome&#8217; has often been used in the last decade to define this interdependency of the kidneys and the heart&#44; and as an umbrella term for worse outcome when the two organs fail simultaneously&#46; A recent review of the pathophysiological pathways of this syndrome was recently published by Schefold et al&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">1</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Although the concept of the cardiorenal syndrome is helpful when describing these heart-kidney interactions&#44; it should be emphasized that the current definition of cardiorenal syndrome includes all forms of two-way connections and is not specific to HF&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">That being said&#44; it is widely documented that renal dysfunction occurs frequently in all phenotypes of HF&#44; and when present&#44; is associated with higher mortality and morbidity&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Over 50 studies have been published describing the association between renal dysfunction and mortality in HF&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a> The majority of these studies were observational&#44; since most randomized clinical trials on HF exclude patients with moderate to severe chronic kidney disease &#40;CKD&#41;&#46; However&#44; two landmark retrospective analyses of randomized controlled trials showed that reductions in estimated glomerular filtration rate &#40;eGFR&#41; were associated with higher mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3&#44;4</span></a></p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Worsening renal function</span><p id="par0030" class="elsevierStylePara elsevierViewall">Several meta-analyses have also demonstrated that worsening renal function &#40;WRF&#41; is associated with increased mortality in both inpatients and outpatients&#44; with larger increases in serum creatinine predicting worse outcomes&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2&#44;5&#44;6</span></a> It has been observed that even a small increase in serum creatinine during hospitalization&#44; as low as 0&#46;2 mg&#47;dl&#44; is associated with poor outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">However&#44; at least in acute decompensated heart failure &#40;ADHF&#41;&#44; some increase in serum creatinine may be acceptable&#44; as long as the patient&#39;s overall clinical status does not deteriorate&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a> Patients with WRF and some degree of hemoconcentration&#44; decongestion&#44; or reduction in blood pressure resulting from acute HF treatment&#44; especially with diuretics&#44; have a much better outcome than those who have WRF that appears to be unprovoked&#46;<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">9&#8211;11</span></a> In other words&#44; as suggested by Damman et al&#46;&#44; if a patient&#39;s clinical status improves or remains the same and their serum creatinine increases&#44; this &#8216;pseudo-WRF&#8217; may not necessarily mean a poor prognosis&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">On the other hand&#44; Gottlieb et al&#46; found that 47&#37; of patients admitted for ADHF had WRF during the first three days of hospitalization&#44; when they were still hypervolemic&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a> This finding challenges the common conception that worsening renal function in ADHF is due to decreased intravascular volume and&#47;or low cardiac output&#46; Clearly overdiuresis and lowering filling pressure can potentially worsen renal function&#44; but this is not the case in almost half of ADHF admissions&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Renal function on admission for decompensated heart failure</span><p id="par0045" class="elsevierStylePara elsevierViewall">According to Damman et al&#46;&#44; around 4&#46;5&#37; of the general population have eGFR &#60;60 ml&#47;min&#47;1&#46;73 m<span class="elsevierStyleSup">2</span>&#44; normally classified as chronic kidney disease &#40;CKD&#41;&#44; while over 50&#37; of patients with acute and chronic HF &#40;both preserved and reduced ejection fraction&#41; have a similar reduction in eGFR&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">It is therefore not surprising that a large percentage of patients admitted to hospital with ADHF present with some degree of renal dysfunction&#46; The exact proportion varies according to the definition of renal failure and the methods used to determine renal function&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Determination of the prognostic significance of low eGFR in ADHF patients on admission in the real world could provide valuable information&#44; considering the increased risk of these patients and the potential implications for therapeutic choices&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">It is well known that patients with renal dysfunction are less likely to be treated with drugs like angiotensin-converting enzyme inhibitors&#44; angiotensin receptor blockers&#44; spironolactone or sacubitril&#44; that can improve HF prognosis&#44; for fear of causing renal dysfunction and electrolyte imbalance&#46;</p><p id="par0065" class="elsevierStylePara elsevierViewall">The study by Formiga et al&#46; published in this issue of the <span class="elsevierStyleItalic">Journal</span><a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> sheds more light on this important subject&#46; This observational study included nearly 1000 patients with a first episode of ADHF &#40;52&#46;3&#37; of whom had eGFR &#60;60 ml&#47;min&#41;&#44; and assessed the one-year prognostic significance of renal dysfunction on admission&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">The study&#39;s strengths and limitations are well described in the discussion of the paper and should be taken into account when analyzing its results and conclusions&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">In our view&#44; the major limitation of this paper &#40;which is also acknowledged by the authors&#41; lies in the fact that data on changes in patients&#8217; eGFR during and after hospitalization were not collected&#44; and so the role of worsening or improving renal function &#40;beyond the spot admission data&#41; in the prognosis of the study population could not be assessed&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Despite this limitation&#44; the study&#39;s results support the authors&#8217; conclusions that assessment of renal failure by the determination of admission eGFR has significant short- and medium-term prognostic value&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">In conclusion&#44; careful reading of Formiga et al&#46; is recommended and physicians should understand that patients with combined renal and heart failure have problems that are more than the sum of these diseases alone&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">The management of these patients cannot be based on treating both diseases as separate entities&#46; Many pathophysiological and therapeutic factors must be taken into account and a balance sought between hemodynamic and renal factors for each individual&#46; Getting this balance right can favorably modify the patient&#39;s prognosis&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflicts of interest</span><p id="par0095" class="elsevierStylePara elsevierViewall">Daniel Ferreira has received honoraria &#40;advisory board member and&#47;or invited speaker&#41; from Astellas&#44; Astra-Zeneca&#44; Bayer&#44; BMS&#47;Pfizer&#44; Boehringer-Ingelheim&#44; Novartis&#44; and Sanofi-Aventis&#46;</p></span></span>"
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