Renal dysfunction in acute and chronic heart failure: prevalence, incidence and prognosis John G. F. Cleland • Valentina Carubelli • Teresa Castiello • Ashraf Yassin • Pierpaolo Pellicori • Renjith Antony Published online: 17 March 2012 Ó Springer Science+Business Media, LLC 2012 Abstract Most patients with heart failure have mild or moderate renal dysfunction. This reflects the combined impact of chronic renal parenchymal disease, renal artery disease, renal congestion and hypoperfusion, neuroendocrine and cytokine activation and the effects of treatments for heart failure. Remarkably, with good treatment, the average annual rate of decline in renal function is similar in patients with chronic heart failure and healthy people of a similar age. Urea appears to be a stronger marker of an adverse prognosis than creatinine-based measures of renal function. Recent evidence suggests that minor, transient increases in creatinine in the setting of acute heart failure are not prognostically important but persistent deterioration does indicate a higher mortality. The poor prognosis of patients with worsening renal function ensures that few require renal dialysis but this may change as methods to prevent sudden death improve and new ways are found to control fluid congestion. Reversing renal dysfunction and stopping its progression remain important targets for treatment of heart failure. Keywords Renal dysfunction Á Heart failure Á Prognosis Á Prevalence Á Incidence Introduction Over the last decade, research has shown that renal dys- function is a major determinant of outcome in patients with heart failure. This has given rise to the concept of a car- diorenal syndrome [1, 2] with a ‘vicious cycle’ of deteri- oration, but whether the heart is the ‘chicken’ or the ‘egg’ in this concept is unclear. It is likely that the aetiology of renal dysfunction in patients with heart failure is much more complex (Fig. 1) and represents a matrix of interac- tions and the sum total of independent but interacting processes with effects on both the kidney and the heart. This article provides an updated review of the prevalence and prognostic significance of renal dysfunction in acute and chronic heart failure. In addition, this review will consider the aetiology of renal dysfunction and its natural history in patients with heart failure; when does it occur, is it reversible and how fast does it progress? Which renal marker? For more than 100 years, clinicians have used measurements of creatinine as an index of renal function. Most of the epi- demiology of renal dysfunction focuses either on serum cre- atinine itself or on calculated creatinine clearance using either the Cockroft–Gault or one of the ‘modification of diet in renal disease’ (MDRD) equations to estimate glomerular filtration rate (eGFR) [3]. These various measures of renal function are highly correlated. In multivariable prognostic models, serum creatinine performs about as well as the derived measures since these models usually already contain all of the variables in the equation used to calculate renal function, such as age, sex and body mass. However, in some groups of patients, for instance, those with muscle wasting or cachexia, creatinine- based measurements may underestimate the severity of renal dysfunction [3]. There is growing evidence that other blood markers of renal dysfunction including cystatin-C [4, 5] and serum J. G. F. Cleland (&) Á V. Carubelli Á T. Castiello Á A. Yassin Á P. Pellicori Á R. Antony Department of Cardiology, Hull York Medical School, University of Hull, Castle Hill Hospital, Kingston upon Hull HU16 5JQ, UK e-mail: j.g.cleland@hull.ac.uk 123 Heart Fail Rev (2012) 17:133–149 DOI 10.1007/s10741-012-9306-2