The Cardio-Renal Anemia Syndrome – An Historical Perspective

1
The Cardio-Renal Anemia Syndrome An Historical
Perspective

• Donald Silverberg
• Department of Nephrology
• Tel Aviv Medical Center
• Israel

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Outline

• History of anemia in CHF and CKD
• Defining CRAS
• What does CRAS therapy mean?
• The future

CHF, chronic heart failure CKD, chronic kidney
disease CRAS, Cardio-Renal Anemia Syndrome
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Anemia Therapy Improves Numerous Factors
Associated with CRAS

• Anemia therapy
• Improved Hb levels
• Improved NYHA class
• Increased Exercise tolerance 
• Improved QoL
• Improved LVEF
• Reduced BNP
• Reduced risk of CHF-related hospitalization
• Reduced risk of all cause mortality

Ngo K et al. Cochrane Database Syst Rev
20101CD007613
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Anemia, CKD and CHF Commonly Appear Together in
Individual Patients
Observation that many patients with CKD and
anemia also have CHF
Observed 50 of patients with CHF have anemia
and that low Hb is related to worse NYHA class
Correction of anemia with i.v. iron and ESA in
patients with CKD positively affected CKD
progression, NYHA class and QoL
Correction of anemia in patients with CHF
produced similar results to those observed in
patients with CKD and CHF
Late 1990s
Hb, hemoglobin NYHA, New York Heart Association
QoL, quality of life
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Studies and Meta-analyses Demonstrate the Links
Between CHF, CKD and Anemia
The term CRAS is first coined by Silverberg and
colleagues (2002)
Numerous publications examining the effect of
i.v. iron and ESAs in CHF and CKD patients with
anemia
CRAS 2010 Working Together to Improve Patient
Outcomes
2010
Growing evidence and meta-analyses have
demonstrated the link between renal failure,
heart failure and anemia
I.v., intravenous ESA, erythropoiesis-stimulating
agent
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The First Definition of CRAS

• We proposed the term Cardio-Renal Anemia Syndrome
  (CRAS) 10 years ago to suggest that there is an
  interaction between renal failure, heart failure
  and anemia

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CRAS is a Vicious Cycle
Anemia
Heartfailure
Renalfailure
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What does CRAS Therapy Mean?

• Good treatment of heart failure will prevent
  progression of anemia and renal failure
• Good treatment of anemia will prevent progression
  of heart failure and renal failure
• Good treatment of renal failure will prevent
  progression of anemia and heart failure

i.v. iron and ESA therapy should provide the
backbone for CRAS therapy
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The Future of the Field

• Greater awareness of CRAS among cardiologists and
  nephrologists
• Multidisciplinary teams to treat CHF and CKD
• We are on the verge of breakthrough studies due
  to address iron deficiency and CRAS
• Greater awareness of iron deficiency
• Perhaps CRAS should be changed to the
  Cardio-Renal Anemia Iron Deficiency Syndrome
  (CRAIDS)
• Can i.v. iron be used to treat CRAS without ESAs?
• Future studies?