الفهرس 
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Abstract
Acute renal failure with other organ failure in critically ill patients is a hazardous issue can be encountered in ICU medicine where renal failure may be associated with other system failure e.g. heart failure, respiratory failure or hepatic failure.Bi-system failure may occur simultaneously at the same time or one system may precedes the other in a causal relationship reflecting the integrity of our body where each system integrates with the others upholding benefits of the whole body & achieving homeostasis.
Cardiorenal syndrome: refers to renal & cardiac disorders whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction of the other. It includes 5 types:
Type 1CRS: also called acute cardiorenal syndrome, in which primary ADHF leads to AKI via hemodynamic, neurohumoral, hormonal mechanisms.
Treatment:
1- Supportive (oxygen, relieve pain & avoid nephrotoxins)
2- Treatment of hypervolemia (diuretics, vasodilators, extracorporeal ultrafiltration may be needed in diuretic resistance).
3- Treatment of tachyarrhythmias (e.g. lanoxin in AF).
4- Treatment of cardiogenic shock (inotropes, vasopressors, intra-aortic balloon pump & ventricular assist device)
Type 2 CRS: also called chronic cardiorenal syndrome, in which primary CHF leads to CKD via chronic renal hypoperfusion & accelerated atherosclerosis.
Treatment:
1. Exclude precipitating pre-renal AKI factors, adjust therapy & avoid nephrotoxinswith careful monitoring of renal function & electrolytes with ACE inhibitors, ARBs & diuretics.
2. ACE inhibitors and ARBs, beta-blockers, & aldosterone antagonists significantly reduce mortality and morbidity in CHF.
3. Hydralazine and nitrates in patients unable to tolerate the above mentioned agents.
4. Digoxin and diuretics (in hypervolemic patient) improve symptoms in CHF but have no effect on mortality.
5. Treatment of anemia.
6. RRT may be required in refractory cases.
7. Implantable cardiac defibrillators, mechanical assist devices and/or cardiac transplantation
Type 3 CRS: also called acute renocardiac syndrome, in which primary AKI leads to acute cardiac dysfunction such as arrhythmia, ACS, acute pulmonary oedema & ADHF occurs through high preload, neurohumoral changes and electrolytes & acid base imbalance. A typical clinical scenario would include AKI following contrast exposure, or following cardiovascular surgery.
Treatment:
1. Treatment of the cause, exclude renovascular disease and consider early renal support, if diuretic resistant.
2. Avoid contrast nephropathy with isotonic fluids &N-acetylcysteine
Type 4 CRS: also called chronic renocardiac syndrome, characterized by CKD that contributes to cardiovascular disease (CVD) caused by chronic hypoxemia, neurohumoral, salt and water retention & uremic toxins.
Treatment:
1. Exclude precipitating causes, avoid hypervolemia & positive sodium balance.
2. Treatment of heart failure.
3. Consider early renal replacement therapy.
4. Correcting anaemia
Type 5 CRS: Also called secondary CRS, characterized by systemic conditions (such as sepsis and SLE) causing simultaneous dysfunction of heart and kidneys occur via hemodynamic, neurohumoral, hypoxemia & lipopolysaccharides.