Dr Rutecki is with the Cleveland Clinic National Consultation Service.
When both heart and kidney succumb to hypertensive damage, results are often devastating. Pickering syndrome is a case in point.
Hypertension discriminates poorly among target organs and quite often adversely affects the heart and kidney simultaneously. Morbidity and mortality associated with hypertension-mediated damage in these two organ systems is linked to two culprit syndromes in particular-cardiorenal and Pickering syndromes.
How familiar are you with either? Both?
Let’s start with a simple true or false.
There are 2 basic types of cardiorenal syndrome.
The correct answer is B. False
There are 4 different types of cardiorenal syndrome1 :
A. Acute heart failure (HF) leading to acute renal failure.
B. Chronic HF leading to progressive chronic kidney disease (CKD).
C. Acute kidney failure (the primary pathology) leading to HF (from volume overload).
D. Progressive CKD (the primary pathology) leading to heart failure (from volume overload).
Note in options (A) and (B) that primary HF is the cause of renal insufficiency (including, but not limited to renal underperfusion). In options (C) and (D) the converse pertains-heart failure is secondary to kidney disease. However, in varieties C and D, there is also some degree of hypertensive heart disease. The first article in this hypertension target organ series looked at HF as a consequence of hypertension.2 In real life, a heart damaged by hypertension leads to ineffective perfusion of a kidney that may have hypertensive damage itself (from nephrosclerosis) or injury from another common comorbid condition like diabetes. However, primary renal disease can secondarily cause HF from volume overload. Cardiorenal syndrome is a huge problem because decreasing glomerular filtration rates can compromise potassium excretion, leading to hyperkalemia. The medications prescribed for HF and hypertension-ACEIs, ARBs, and spironolactone-can further aggravate hyperkalemia. In short, renal insufficiency and HF are “partners in crime.”
Which definition below best describes “Pickering syndrome”?
A. Progressive CKD leading to HF.
B. Acute renal insufficiency from ACEI therapy.
C. “Flash” pulmonary edema with bilateral atheromatous renal artery stenosis or renal artery stenosis in a solitary-functioning kidney.
D. Volume overload in dialysis patients when they miss a dialysis treatment.
The correct answer is C. Pickering syndrome is the clinical entity of “flash” pulmonary edema with bilateral atheromatous renal artery stenosis or renal artery stenosis in a solitary-functioning kidney.1,3
First, what is the clinical entity referred to as “flash” pulmonary edema? It is acute pulmonary edema, literally occurring in minutes. What are the predisposing conditions? Usually a combination of impaired left ventricular filling as a consequence of hypertension-induced hypertrophy accompanied by bilateral renal artery stenosis or high grade stenosis to a solitary functioning kidney-pulmonary edema occurs rapidly.1 To avoid recurrent pulmonary edema, the renal artery problem has to be rectified via bypass surgery (better) or by stenting.
The critical relationship between the kidney and heart can be altered as a consequence of hypertensive damage to either or both. When hypertensive heart damage is primary, underperfusion of a normal kidney can lead to acute renal failure. Diseased kidneys can cause volume overload in a heart affected by hypertension-induced hypertrophy (HF with preserved systolic function). When both organs are adversely affected by hypertension (diastolic dysfunction, CKD, renal vascular disease-all complications of hypertension) adverse outcomes may include cardiorenal or Pickering syndromes.
1. Messerli FH, Rimoldi SF, Bangalore S. The transition from hypertension to heart failure: contemporary update. JACC. 2017; Article in Press.
2. Rutecki GW. Blood pressure and target organ damage: The heart. Part 1. Practical Cardiology. Available at http://practicalcardiology.modernmedicine.com/practical-cardiology/news/blood-pressure-and-target-organ-damage-heart3. Pickering TG, Herman L, Devereux RB, et al. Recurrent pulmonary oedema in hypertension due to bilateral artery stenosis: treatment by angioplasty or surgical revascularization. Lancet 1988; 2:551-552.