Renal Insufficiency and Heart Failure Illustration

Renal Insufficiency and Heart Failure: An Overview (2024)

by | Updated: Apr 6, 2024

Renal insufficiency and heart failure are two interconnected medical conditions that often coexist, magnifying the complexities of patient care.

The kidney’s regulatory role in fluid and electrolyte balance and its intricate relationship with the cardiovascular system make it both a contributor to and a victim of cardiac dysfunction.

Understanding the mechanisms linking these two conditions is vital for improved patient outcomes and offers insights into potential therapeutic interventions.

Free Access
25+ RRT Cheat Sheets and Quizzes

Get instant access to 25+ premium quizzes, mini-courses, and downloadable cheat sheets for FREE.

How are the Heart and Kidneys Related?

The heart and kidneys maintain a bidirectional relationship. The heart pumps blood to the kidneys, ensuring adequate filtration. In turn, the kidneys regulate fluid and electrolyte balance, influencing blood volume and pressure. Dysfunction in one organ can affect the other, as seen in cardiorenal syndrome, where heart failure and renal insufficiency coexist.

Relationship Between the Heart and Kidneys Vector

What is Renal Insufficiency?

Renal insufficiency, often referred to as chronic kidney disease (CKD) when it persists over time, is a medical condition characterized by the diminished ability of the kidneys to perform their essential functions.

The kidneys play a crucial role in filtering waste products and excess fluids, including electrolytes, from the blood to form urine.

When their function is compromised, harmful waste products can accumulate in the body, leading to a range of potential complications.


The symptoms of renal insufficiency can vary but commonly include:

  • Fatigue and weakness
  • Changes in urine output
  • Swelling or edema
  • Shortness of breath
  • Nausea and vomiting
  • Loss of appetite
  • Metallic taste in the mouth or bad breath
  • Cognitive changes
  • Itching
  • Muscle cramps or twitches
  • Bone pain or fractures
  • Cold intolerance
  • Pale skin
  • High blood pressure

The causes of renal insufficiency can be diverse, including but not limited to diabetes, hypertension, chronic glomerulonephritis, polycystic kidney disease, and prolonged use of certain medications.

Regular monitoring and timely medical intervention are crucial to manage renal insufficiency and prevent its progression to end-stage renal disease (ESRD), which might necessitate treatments like dialysis or kidney transplantation.

What is Heart Failure?

Heart failure is a chronic, progressive condition in which the heart muscle is unable to pump blood efficiently enough to meet the body’s needs.

Contrary to its name, “heart failure” doesn’t mean the heart has stopped or is about to stop working. Instead, it signifies that the heart is not functioning as effectively as it should.


The symptoms of heart failure can vary but commonly include:

  • Shortness of breath (dyspnea)
  • Fatigue and weakness
  • Swelling (edema) in the legs, ankles, and feet
  • Persistent cough or wheezing with white or pink blood-tinged phlegm
  • Rapid or irregular heartbeat
  • Reduced ability to exercise
  • Swelling of the abdomen (ascites)
  • Sudden weight gain from fluid retention
  • Nausea or lack of appetite
  • Difficulty concentrating or decreased alertness

The causes of heart failure can be varied, but common contributors include coronary artery disease, high blood pressure, diabetes, certain medications, and chronic diseases that damage the heart or its valves.

Management and treatment of heart failure aim to improve symptoms, enhance the quality of life, and increase lifespan. This is achieved through medications, lifestyle modifications, and, in some cases, medical devices or surgical procedures.

Early diagnosis and management are critical to improve outcomes and prevent the progression of the disease.

Relationship Between the Heart and Kidneys

The heart and kidneys share a complex and bidirectional relationship, each influencing the function of the other.

Their interconnectedness is so profound that dysfunction in one organ can precipitate or exacerbate dysfunction in the other. This intricate relationship is commonly referred to as the cardiorenal syndrome.

Here are some of the key aspects of the relationship between the heart and kidneys:

  • Hemodynamic Relationship: The kidneys receive about 20-25% of the cardiac output. Adequate blood flow and pressure are essential for the kidneys to function properly. Conversely, the kidneys, through the renin-angiotensin-aldosterone system (RAAS), regulate blood volume and systemic vascular resistance, thus influencing blood pressure and cardiac workload.
  • Volume Regulation: The kidneys play a pivotal role in fluid balance by excreting or conserving water and salt. Fluid overload, often due to reduced kidney function, can exacerbate heart failure. Conversely, decreased cardiac output in heart failure can lead to decreased kidney perfusion and, thus, reduced urine output, leading to fluid retention.
  • Neurohormonal Activation: In conditions like heart failure, reduced cardiac output and kidney perfusion can stimulate the RAAS and sympathetic nervous system. This can lead to vasoconstriction, sodium retention, and fluid overload, further stressing both the heart and kidneys.
  • Toxin Removal: The kidneys are responsible for removing various waste products from the blood. In renal insufficiency, these toxins accumulate and can have direct and indirect negative effects on cardiac structure and function.
  • Medication and Treatment Impacts: Many medications used to treat heart conditions can affect kidney function and vice versa. Diuretics, commonly used in heart failure, can lead to electrolyte imbalances and kidney dysfunction if not monitored and dosed appropriately.
  • Chronic Activation and Remodeling: Chronic kidney disease can lead to systemic inflammation, oxidative stress, and increased levels of certain hormones that can have detrimental effects on the heart, leading to hypertrophy (enlargement) and fibrosis (scarring).
  • Shared Risk Factors: Both heart disease and kidney disease share common risk factors like hypertension, diabetes, obesity, and smoking. The presence of these risk factors can simultaneously harm both organs.

Note: The relationship between the heart and kidneys demands an integrated approach. Recognizing the influence of one organ on the other is crucial for effective patient management. Optimizing the function of one often benefits the other, highlighting the importance of a holistic approach in patients with cardiorenal involvement.

Practice Questions About Heart Failure and Renal Insufficiency

1. What is renal failure?
The inability to maintain fluid, electrolytes, and acid-base balance, excrete waste products, and maintain metabolic functions.

2. What is acute renal failure?
A decrease in creatinine clearance over several days, which often has symptoms and many causes.

3. What is chronic renal failure?
The slow, steady deterioration of renal function that is usually due to diabetes or hypertension. You will only see symptoms in the severe stages.

4. What is the composition of the blood largely determined by?
It is determined by what the kidneys retain and excrete.

5. How do you treat chronic renal failure?
You should treat the symptoms with dialysis and antihypertensives.

6. What is dialysis?
It is a procedure for filtering the blood in place of kidney function that maintains fluid status, pH, and removes nitrogenous waste.

7. What is hemodialysis?
A process where blood goes through a dialyzer, which is a semipermeable membrane filter.

8. What is the function of the kidneys?
They filter dissolved particles from the blood and selectively reabsorb substances needed to maintain the normal composition of body fluids.

9. What cardiopulmonary problems occur when the kidneys fail?
Hypertension, congestive heart failure (CHF), pulmonary edema, anemia, and pH changes.

10. What are nephrons?
They are the functional units of the kidneys. Each kidney has approximately 1 million nephrons, which consist of the glomerulus, proximal convoluted tubule, loop of Henle, and distal convoluted tubule.

11. What are the three things involved in urine formation?
Glomerular filtration, tubular reabsorption, and tubular secretion.

12. What is glomerular filtration?
Water and dissolved substances (electrolytes) are forced out of glomerular capillaries into Bowman’s capsule. The rate of filtration (GFR) is directly proportional to the hydrostatic pressure of the blood. About 125 mL of fluid/min is filtered, but only 1 mL/min is excreted.

13. What is the glomerular filtration rate?
The rate at which water and dissolved substances (electrolytes) are forced out of the glomerular capillaries into the Bowman’s capsule. This rate is directly proportional to the hydrostatic pressure of the blood. The normal rate is 125 mL/min. GFR is the best overall index of kidney function. Normal GFR varies according to age, sex, and body size and declines with age.

14. Why are there two sets of arterioles in the blood flow of the kidneys?
There are two sets of arterioles in kidney blood flow (the afferent arterioles and efferent arterioles) because arterioles help regulate blood pressure in the glomerulus so that it is just right for glomerular filtration. Arterioles are resistance vessels, meaning they can vasodilate or vasoconstrict to adjust blood pressure.

15. What are the two ways the kidneys can concentrate or dilute urine?
Countercurrent mechanism and selective permeability

16. What ions do the kidneys help regulate?
Sodium, potassium, calcium, magnesium, and phosphate.

17. What are the kidneys shaped like?
They are bean-shaped organs.

18. What is the hilum?
The central concave portion of each part of the kidney that has a longitudinal fissure. The renal artery, renal vein, and nerves enter and leave the kidneys through the hilum.

19. What are the ureters?
They transport urine from the kidney to the bladder.

20. What is the cortex?
The outer one-third of the kidney

21. What is the medulla?
The middle portion of the kidney

22. How is blood supplied to the kidneys?
From the right and left renal arteries

23. What are the collecting ducts?
A functional part of the nephron that plays a role in urine concentration, ion salvaging, and acid-base balance.

24. Where is urine formed?
The nephrons of the kidneys

25. How is sodium controlled?
It is controlled by the regulation of water in the body.

26. What happens when there is high potassium?
It causes muscle weakness, metabolic acidosis, and life-threatening arrhythmias.

27. What is the correlation between mechanical ventilation and renal failure?
Increased pressure during mechanical ventilation decreases venous return to the heart, causing the pressure and blood volume in the atria to decrease. This triggers more ADH to be released, and the amount of urine produced decreases.

28. What does Bowman’s capsule do?
It collects filtrates from the glomerulus.

29. What does the glomerulus do?
It squeezes fluid (i.e., water, glucose, salts, and urea) out of the blood into Bowman’s Capsule.

30. What does the Loop of Henle do?
It concentrates filtrates and allows the diffusion of salts and water back into the blood.

31. What does the distal convoluted tubule do?
It filters out sodium, potassium, and calcium.

32. What does the collecting duct do?
It collects urine to be excreted.

33. What is the renal artery?
A blood vessel that carries blood to the kidneys.

34. What is the renal vein?
A blood vessel that carries blood away from the kidneys toward the heart.

35. What is the renal pelvis?
The collection site for urine before it exits the kidney.

36. What is the afferent arteriole?
It carries blood toward the glomerulus.

37. What is the efferent arteriole?
It carries blood out of the glomerulus.

38. What is the renal cortex?
It is the outer layer of the kidney.

39. What is the renal medulla?
The whole inner portion of the kidney.

40. Where is ADH released?
Posterior pituitary

41. What happens when ADH is low?
The collecting duct is impermeable to water, so water must be excreted, producing high-volume dilute urine.

42. What happens when ADH is high?
The distal tubule and collecting duct are made permeable to water and urea.

43. What is the function of aldosterone?
It causes the kidneys to conserve sodium and water.

44. What is the effect of increased sympathetic activity and the presence of angiotensin II?
It causes the pituitary gland to release anti-diuretic hormone.

45. What is the function of ADH?
It causes the kidney to conserve water, increasing blood volume and vasoconstriction.

46. What governs blood flow to tissue?
Intrinsic factors

47. What governs arterial blood pressure?
Extrinsic mechanisms

48. What is active hyperemia?
An increase in organ blood flow that is associated with increased metabolic activity of a tissue or organ.

49. What does oxygen do to blood vessels in systemic circulation?
It causes vasoconstriction.

50. What is the effect of vasodilated blood vessels within systemic circulation due to decreased oxygen?
Increased blood supply

51. What breathing pattern is often present during renal failure?
Kussmaul breathing

52. What breath sounds are present during renal failure?
Crackles are likely, especially if the patient also has CHF.

53. What is the expected fluid output for someone with renal failure?
Less than 500 mL per day

54. Which blood test is helpful in diagnosing renal failure?

55. What are three of the top causes of kidney failure?
Diabetes, hypertension, and chronic glomerulonephritis

Final Thoughts

In summarizing the relationship between renal insufficiency and heart failure, it’s evident that the intertwined pathology of these conditions demands an integrated clinical approach.

As advancements in medical research continue, a holistic understanding of how these systems influence one another becomes paramount.

Future therapeutic strategies should target both the heart and kidneys, recognizing the symbiotic relationship between these vital organs and the importance of their mutual functionality for overall health.

John Landry, BS, RRT

Written by:

John Landry, BS, RRT

John Landry is a registered respiratory therapist from Memphis, TN, and has a bachelor's degree in kinesiology. He enjoys using evidence-based research to help others breathe easier and live a healthier life.


  • Faarc, Kacmarek Robert PhD Rrt, et al. Egan’s Fundamentals of Respiratory Care. 12th ed., Mosby, 2020.
  • Jardins, Des Terry. Cardiopulmonary Anatomy & Physiology: Essentials of Respiratory Care. 7th ed., Cengage Learning, 2019.
  • Rrt, Des Terry Jardins MEd, and Burton George Md Facp Fccp Faarc. Clinical Manifestations and Assessment of Respiratory Disease. 8th ed., Mosby, 2019.
  • “Chronic Kidney Disease and Its Complications.” National Center for Biotechnology Information, June 2008.
  • “Cardiovascular Risk Factors and Incident Acute Renal Failure in Older Adults: The Cardiovascular Health Study.” National Center for Biotechnology Information, Mar. 2008.
  • “Cardiovascular Disease in Patients with Chronic Kidney Disease: A Neglected Subgroup.” National Center for Biotechnology Information, 2016.

Recommended Reading