Strategies for the Management of Cardiorenal Syndrome in the Acute Hospital Setting
Round 1
Reviewer 1 Report
Comments and Suggestions for Authors
The review was aimed to focus on type 1 CRS. There are several significant points that authors should consider.
If the review aims to clarify the diagnostic and therapeutic approaches to CRS in the acute setting, each section should focus on how the different therapeutic approaches affect the prevention and risk of the onset of type 1 CRS. This does not seem to be the primary point in most of the paragraphs.
A paragraph on the definition of type 1 CRS, based essentially on the definition of AKI, should also be added.
- The possible role of diuretics in worsening renal function needs to be better described. In particular, the worsening of renal function could be linked to sequential blockade.
- CARESS has a study design according to which randomization occurred in case of worsening of renal function. This is relevant to underline the applicability of this treatment in CRS
- levosimendan has been associated, in some studies, with an improvement in renal function. These studies should be reported
- in the acute setting, sacubitril/valsartan was evaluated in the PIONEER study. Data relating to the association with type 1 CRS in the trial should be reported
- Similarly, acute studies of SGLT2i and their renal end-points should be reported.
- The need for a section on palliative care is unclear
Author Response
We thank the reviewers for their time and valuable comments. We have diligently considered all the comments and have revised the manuscript extensively according to their suggestions. We sincerely thank the reviewers for these suggestions, which have enhanced the quality of the manuscript. All the changes made are highlighted as requested by the journal.
Comment 1: If the review aims to clarify the diagnostic and therapeutic approaches to CRS in the acute setting, each section should focus on how the different therapeutic approaches affect the prevention and risk of the onset of type 1 CRS. This does not seem to be the primary point in most of the paragraphs.
Response: Thank you for your valuable suggestion. We have added these (lines 66, 140, 175, 180, 285, 358)
Comment 2: A paragraph on the definition of type 1 CRS, based essentially on the definition of AKI, should also be added
Response: Thank you for your valuable suggestion. We have added this, line 45.
Comment 3: The possible role of diuretics in worsening renal function needs to be better described. In particular, the worsening of renal function could be linked to sequential blockade.
Response: Thank you for your valuable suggestion. We have added a paragraph, line 145.
Comment 4: CARESS has a study design according to which randomization occurred in case of worsening of renal function. This is relevant to underline the applicability of this treatment in CRS
Response: Thank you for your valuable suggestion. We have added this, line 205.
Comment 5: Levosimendan has been associated, in some studies, with an improvement in renal function. These studies should be reported
Response: Thank you for your valuable suggestion. We have added this, line 254.
Comment 6: in the acute setting, sacubitril/valsartan was evaluated in the PIONEER study. Data relating to the association with type 1 CRS in the trial should be reported
Response: Thank you for your valuable suggestion. We have added this, line 299
Comment 7: Similarly, acute studies of SGLT2i and their renal end-points should be reported.
Response: Thank you for your valuable suggestion. We have added a paragraph, line 361
Comment 8: The need for a section on palliative care is unclear
Response: Thank you for your valuable question. We added this section for completion's sake. We want to convey to the readers that in advanced CHF and end-stage heart disease, palliative care is important, and the section guides readers to address certain issues.
Reviewer 2 Report
Comments and Suggestions for Authors
This a well written and thorough review on strategies in the management of type 1 Cardiorenal syndrome
covering
The assessment of volume status and surrogate monitoring of cardiac and renal perfusion
The important role of diuretics and management of diuretic refractoriness
Application of Goal-directed therapy
Ancillary methods CRT etc
Management of complications
The paper can be improved with minor revisions
1. Line 65 needs reference
2. The author should discuss the bedside clinical assessment of perfusion in patients with cardiorenal syndrome such as: the warm and dry patient the warm and wet patient, the cold and dry patient and the cold and wet patient. see Haase M., Müller C., Damman K., Murray P.T., Kellum J.A., Ronco C., McCullough P.A. Pathogenesis of cardiorenal syndrome type 1 in acute decompensated heart failure: Workgroup statements from the eleventh consensus conference of the Acute Dialysis Quality Initiative (ADQI) Contrib. Nephrol. 2013;182:99–116
When discussing diuretic therapy the author should discuss should diuretic be discontinued when renal function worsens i.e. permissive worsening renal function.
A table demonstrating trials mentioned in text and outcomes
Author Response
We thank the reviewers for their time and valuable comments. We have diligently considered all the comments and have revised the manuscript extensively according to their suggestions. We sincerely thank the reviewers for these suggestions, which have enhanced the quality of the manuscript. All the changes made are highlighted as requested by the journal.
- Line 65 needs reference
- The author should discuss the bedside clinical assessment of perfusion in patients with cardiorenal syndrome such as: the warm and dry patient the warm and wet patient, the cold and dry patient and the cold and wet patient. see Haase M., Müller C., Damman K., Murray P.T., Kellum J.A., Ronco C., McCullough P.A. Pathogenesis of cardiorenal syndrome type 1 in acute decompensated heart failure: Workgroup statements from the eleventh consensus conference of the Acute Dialysis Quality Initiative (ADQI) Contrib. Nephrol. 2013;182:99–116
When discussing diuretic therapy the author should discuss should diuretic be discontinued when renal function worsens i.e. permissive worsening renal function.
A table demonstrating trials mentioned in text and outcomes
Comment 1: Line 65 needs reference
Response: Thank you for your valuable suggestion. We have added a reference
Comment 2: The author should discuss the bedside clinical assessment of perfusion in patients with cardiorenal syndrome such as: the warm and dry patient the warm and wet patient, the cold and dry patient and the cold and wet patient. see Haase M., Müller C., Damman K., Murray P.T., Kellum J.A., Ronco C., McCullough P.A. Pathogenesis of cardiorenal syndrome type 1 in acute decompensated heart failure: Workgroup statements from the eleventh consensus conference of the Acute Dialysis Quality Initiative (ADQI) Contrib. Nephrol. 2013;182:99–116
Response: Thank you for your valuable suggestion. We have added a paragraph, line 52
Comment 3: When discussing diuretic therapy the author should discuss should diuretic be discontinued when renal function worsens i.e. permissive worsening renal function.
Resposnse: Thank you for your valuable suggestion. We have added a paragraph, line 145
Comment 4: A table demonstrating trials mentioned in text and outcomes
Response: Thank you for your valuable suggestion. We have added tables 1-4
Round 2
Reviewer 1 Report
Comments and Suggestions for Authors
I've no further comment.
