Journal of Nephrology

, Volume 32, Issue 5, pp 699–707 | Cite as

When kidneys and lungs suffer together

  • Claudio SorinoEmail author
  • Nicola  Scichilone
  • Claudio  Pedone
  • Stefano  Negri
  • Dina  Visca
  • Antonio  Spanevello


A significant interaction between kidneys and lungs has been shown in physiological and pathological conditions. The two organs can both be targets of the same systemic disease (eg., some vasculitides). Moreover, loss of normal function of either of them can induce direct and indirect dysregulation of the other one. Subjects suffering from COPD may have systemic inflammation, hypoxemia, endothelial dysfunction, increased sympathetic activation and increased aortic stiffness. As well as the exposure to nicotine, all the foresaid factors can induce a microvascular damage, albuminuria, and a worsening of renal function. Renal failure in COPD can be unrecognized since elderly and frail patients may have normal serum creatinine concentration. Lungs and kidneys participate in maintaining the acid-base balance. Compensatory role of the lungs rapidly expresses through an increase or reduction of ventilation. Renal compensation usually requires a few days as it is achieved through changes in bicarbonate reabsorption. Chronic kidney disease and end-stage renal diseases increase the risk of pneumonia. Vaccination against Streptococcus pneumonia and seasonal influenza is recommended for these patients. Vaccines against the last very virulent H1N1 influenza A strain are also available and effective. Acute lung injury and acute kidney injury are frequent complications in critical illnesses, associated with high morbidity and mortality. The concomitant failure of kidneys and lungs implies a multidisciplinary approach, both in terms of diagnostic processes and therapeutic management.


COPD Pulmonary-renal syndrome Mechanical ventilation Acute lung injury Acute kidney injury 


Compliance with ethical standards

Conflict of interest

The authors disclose all relationships or interests that could have direct or potential influence or impart bias on the work.

Research involving human participants and/or animals

The research does not involve human participants and/or animals.

Informed consent

No informed consent was required.


  1. 1.
    Visconti L, Santoro D, Cernaro V et al (2016) Kidney–lung connections in acute and chronic diseases: current perspectives. J Nephrol 29:341Google Scholar
  2. 2.
    Binda V, Moroni G, Messa P (2018) ANCA-associated vasculitis with renal involvement. J Nephrol 31:197Google Scholar
  3. 3.
    Strojek K, Ziora D, Sroczynski J, Oklek K (1992) Pulmonary complications of type 1 (insulin-dependent) diabetic patients. Diabetologia 35:1173–1176Google Scholar
  4. 4.
    Innocenti F, Fabbri A, Anichini R et al (1994) Indications of reduced pulmonary function in type 1 (insulindependent) diabetes mellitus. Diabetes Res Clin Pract 25:161–168Google Scholar
  5. 5.
    Mori H, Okubo M, Okamura M et al (1992) Abnormalities of pulmonary function in patients with non-insulindependent diabetes mellitus. Intern Med 31:189–193Google Scholar
  6. 6.
    Jubic S, Metelko Z, Car N et al (1998) Reduction of diffusion capacity for carbon monoxide in diabetic patients. Chest 114:1033–1035Google Scholar
  7. 7.
    Arvisi M, Bartolini L, del Borrello P et al (2001) Pulmonary function in non-insulin—dependent diabetes mellitus. Respiration 68:268–272Google Scholar
  8. 8.
    Sandler M (1990) Is the lung a ‘target organ’ in diabetes mellitus? Arch Intern Med 150:1385–1388Google Scholar
  9. 9.
    Gjerde B, Bakke PS, Ueland T, Hardie JA, Eagan TM (2012) The prevalence of undiagnosed renal failure in a cohort of COPD patients in western Norway. Respir Med 106:361–366Google Scholar
  10. 10.
    van Gestel YR, Chonchol M, Hoeks SE et al (2009) Association between chronic obstructive pulmonary disease and chronic kidney disease in vascular surgery patients. Nephrol Dial Transplant 24:2763–2767Google Scholar
  11. 11.
    Incalzi RA, Corsonello A, Pedone C, Battaglia S, Paglino G, Bellia V (2010) Extrapulmonary consequences of COPD in the elderly study investigators. Chronic renal failure: a neglected comorbidity of COPD. Chest 137:831–837Google Scholar
  12. 12.
    Rabe KF, Hurd S, Anzueto A et al (2007) Global initiative for chronic obstructive lung disease. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: gold executive summary. Am J Respir Crit Care Med 176:532–555Google Scholar
  13. 13.
    Mannino DM, Braman S (2007) The epidemiology and economics of chronic obstructive pulmonary disease. Proc Am Thorac Soc 4:502e6Google Scholar
  14. 14.
    Sorheim IC, DeMeo DL, Washko G, Litonjua A, Sparrow D, Bowler R et al (2010) Polymorphisms in the superoxide dismutase-3 gene are associated with emphysema in COPD. COPD 7:262e8Google Scholar
  15. 15.
    Fabbri LM, Luppi F, Beghé B, Rabe KF (2008) Complex chronic comorbidities of COPD. Eur Respir J 31(1):204–212Google Scholar
  16. 16.
    Huiart L, Ernst P, Suissa S (2005) Cardiovascular morbidity and mortality in COPD. Chest 128:2640–2646Google Scholar
  17. 17.
    Fabbri LM, Rabe KF (2007) From COPD to chronic systemic inflammatory syndrome? Lancet 1(9589):797–799 370(Google Scholar
  18. 18.
    Barnes PJ (2013) COPD: Inflammatory mechanisms and systemic consequences. Eur Respir Monograph 59:(13–27)Google Scholar
  19. 19.
    Bon JM, Zhang Y, Duncan SR et al (2010) Plasma infl ammatory mediators associated with bone metabolism in COPD. COPD 7:186–191Google Scholar
  20. 20.
    McAllister DA, Maclay JD, Mills NL et al (2007) Arterial stiffness is independently associated with emphysema severity in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 176(12):1208–1214Google Scholar
  21. 21.
    Elmahallawy II, Qora MA (2013) Prevalence of chronic renal failure in COPD patients. Egypt J Chest Dis Tuberc 62:221–227Google Scholar
  22. 22.
    Cooper RG (2006) Effect of tobacco smoking on renal function. Indian J Med Res 124:261–268Google Scholar
  23. 23.
    Hansen HP, Rossing K, Jacobsen P, Jensen BR, Parving HH (1996) The acute effect of smoking on systemic haemodynamics, kidney and endothelial functions in insulin-dependent diabetic patients with microalbuminuria. Scand J Clin Lab Invest 56:393–399Google Scholar
  24. 24.
    Soriano JB, Visick GT, Muellerova H, Payvandi N, Hansell AL (2005) Patterns of comorbidities in newly diagnosed COPD and asthma in primary care. Chest 128:2099–2107Google Scholar
  25. 25.
    Gan WQ, Man SF, Senthilselvan A, Sin DD (2004) Association between chronic obstructive pulmonary disease and systemic inflammation: a systematic review and a meta-analysis. Thorax 59:574–580Google Scholar
  26. 26.
    Eickhoff P, Valipour A, Kiss D, Schreder M, Cekici L, Geyer K, Kohansal R, Burghuber OC (2008) Determinants of systemic vascular function in patients with stable chronic obstructive pulmonary disease. Am J Respir Crit Care Med 178:1211–1218Google Scholar
  27. 27.
    Andreas S, Anker SD, Scanlon PD, Somers VK (2005) Neurohumoral activation as a link to systemic manifestations of chronic lung disease. Chest 128:3618–3624Google Scholar
  28. 28.
    Hansen JM, Olsen NV, Feldt-Rasmussen B, Kanstrup IL, Dechaux M, Dubray C, Richalet JP (1994) Albuminuria and overall capillary permeability of albumin in acute altitude hypoxia. J Appl Physiol 76:1922–1927Google Scholar
  29. 29.
    John M, Hussain S, Prayle A, Simms R, Cockcroft JR, Bolton CE (2013) Target renal damage: the microvascular associations of increased aortic stiffness in patients with COPD. Respir Res 14:31Google Scholar
  30. 30.
    Corsonello A, Aucella F, Pedone C, Antonelli-Incalzi R (2017) Chronic kidney disease: A likely underestimated component of multimorbidity in older patients with chronic obstructive pulmonary disease. Geriatr Gerontol Int 17:1770–1788Google Scholar
  31. 31.
    Bellia V, Pistelli R, Catalano F et al (2000) Quality control of spirometry in the elderly. The SA.R.A. study. SAlute Respiration nell’Anziano = respiratory health in the elderly. Am J Respir Crit Care Med 161:1094–1100Google Scholar
  32. 32.
    Almagro P, Calbo E, Ochoa de Echagüen A et al (2002) Mortality after hospitalization for COPD. Chest 121(5):1441–1448Google Scholar
  33. 33.
    Middleton RJ, Foley RN, Hegarty J et al (2006) The unrecognized prevalence of chronic kidney disease in diabetes. Nephrol Dial Transplant 21:88–92Google Scholar
  34. 34.
    Corsonello A, Pedone C, Bandinelli S, Ferrucci L, Antonelli Incalzi R (2017) Agreement between chronic kidney disease epidemiological collaboration and Berlin initiative study equations for estimating glomerular filtration rate in older people: the Invecchiare in Chianti (aging in Chianti region) study. Geriatr Gerontol Int 17(10):1559–1567Google Scholar
  35. 35.
    McAlister FA, Ezekowitz J, Tonelli M, Armstrong PW (2004) Renal insufficiency and heart failure: prognostic and therapeutic implications from a prospective cohort study. Circulation 109 (8):1004–1009Google Scholar
  36. 36.
    Bruno CM, Valenti MJ (2012) Acid–base disorders in patients with chronic obstructive pulmonary disease: a pathophysiological review. Biomed Biotechnol 2012:915150. Epub 2012 Feb 1Google Scholar
  37. 37.
    Ucgun I, Oztuna F, Dagli CE, Yildirim H, Bal C (2008) Relationship of metabolic alkalosis, azotemia and morbidity in patients with chronic obstructive pulmonary disease and hypercapnia. Respiration 76(3):270–274.(Epub 2008 May 8)Google Scholar
  38. 38.
    Handy JM, Soni N (2008) Physiological effects of hyperchloraemia and acidosis. Br J Anaesth 101(2):141–150Google Scholar
  39. 39.
    Kraut JA, Madias NE (2010) Metabolic acidosis: pathophysiology, diagnosis and management. Nat Rev Nephrol 6(5):274–285Google Scholar
  40. 40.
    Anand IS, Chandrashekhar Y, Ferrari R et al (1992) Pathogenesis of congestive state in chronic obstructive pulmonary disease: studies of body water and sodium, renal function, hemodynamics, and plasma hormones during edema and after recovery. Circulation 86(1):12–21Google Scholar
  41. 41.
    Ucgun I, Oztuna F, Dagli CE, Yildirim H, Bal C (2008) Relationship of metabolic alkalosis, azotemia and morbidity in patients with chronic obstructive pulmonary disease and hypercapnia. Respiration 76(3):270–274Google Scholar
  42. 42.
    Khilnani GC, Banga A, Sharma SK (2004) Predictors of mortality of patients with acute respiratory failure secondary to chronic obstructive pulmonary disease admitted to an intensive care unit: a one year study. BMC Pulm Med 4:12Google Scholar
  43. 43.
    Banga A, Khilnani GC (2006) A comparative study of characteristics and outcome of patients with acute respiratory failure and acute on chronic respiratory failure requiring mechanical ventilation. Indian J Crit Care Med 10(2):80–87Google Scholar
  44. 44.
    Karacan O, Tutal E, Colak T et al (2006) Pulmonary function in renal transplant recipients and endstage renal disease patients undergoing maintenance dialysis. Transpl Proc 38:396–400Google Scholar
  45. 45.
    Gómez-Fernández P, Sánchez Agudo L, Calatrava JM et al (1984) Respiratory muscle weakness in uremic patients under continuous ambulatory peritoneal dialysis. Nephron 36:219–223Google Scholar
  46. 46.
    Manfredini F, Lamberti N, Malagoni AM et al (2015) The role of deconditioning in the end-stage renal disease myopathy: physical exercise improves altered resting muscle oxygen consumption. Am J Nephrol 41:329–336Google Scholar
  47. 47.
    Pomidori L, Lamberti N, Malagoni AM et al (2016) Respiratory muscle impairment in dialysis patients: can minimal dose of exercise limit the damage? A Preliminary study in a sample of patients enrolled in the EXCITE trial. J Nephrol 29:863–869Google Scholar
  48. 48.
    Turner C, Spanel P, Smith D (2006) A longitudinal study of ammonia, acetone and propanol in the exhaled breath of 30 subjects using selected ion flow tube mass spectrometry, SIFT-MS. Physiol Meas 27(4):321–337Google Scholar
  49. 49.
    Narasimhan LR, Goodman W, Patel CK (2001) Correlation of breath ammonia with blood urea nitrogen and creatinine during hemodialysis. Proc Natl Acad Sci USA 98(8): 4617–4621Google Scholar
  50. 50.
    Simenhoff ML, Burke JF, Saukkonen JJ et al (1977) Biochemical profile of uremic breath. N Engl J Med 297(3):132–135Google Scholar
  51. 51.
    Davies SJ, Španěl P, Smith D (2014) Breath analysis of ammonia, volatile organic compounds and deuterated water vapor in chronic kidney disease and during dialysis. Bioanalysis 6(6):843–857Google Scholar
  52. 52.
    Jankowski J, Westhof T, Vaziri ND et al (2014) Gases as uremic toxins: is there something in the air? Semin Nephrol 34(2):135–150Google Scholar
  53. 53.
    Holland AE, Wilson JW, Kotsimbos TC, Naughton MT. (2003). Metabolic alkalosis contributes to acute hypercapnic respiratory failure in adult cystic fibrosis. Chest 124(2):490–493Google Scholar
  54. 54.
    Sbardella E, Isidori AM, Arnaldi G et al (2018 Jan) Approach to hyponatremia according to the clinical setting: consensus statement from the Italian Society of Endocrinology (SIE), Italian Society of Nephrology (SIN), and Italian Association of Medical Oncology (AIOM). J Endocrinol Invest 41(1):3–19Google Scholar
  55. 55.
    Naqvi SB, Collins AJ (2006) Infectious complications in chronic kidney disease. Adv Chronic Kidney Dis 13(3):199Google Scholar
  56. 56.
    Dalrymple LS, Katz R, Kestenbaum B, de Boer IH, Fried L, Sarnak MJ, Shlipak MG (2012) The risk of infection-related hospitalization with decreased kidney function. Am J Kidney Dis 59(3):356Google Scholar
  57. 57.
    Eleftheriadis T, Liakopoulos V, Leivaditis K et al. (2011) Infections in hemodialysis: a concise review—part 1: bacteremia and respiratory infections. Hippokratia 15(1): 12–17Google Scholar
  58. 58.
    Sarnak MJ, Jaber BL (2001) Pulmonary infectious mortality among patients with end-stage renal disease. Chest 120:1883–1887Google Scholar
  59. 59.
    Robinson J (2004) Efficacy of pneumococcal immunization in patients with renal disease—what is the data? Am J Nephrol 24:402–409Google Scholar
  60. 60.
    Tanzi E, Amendola A, Pariani E, Zappa A, Colzani D, Logias F et al (2007) Lack of effect of a booster dose of influenza vaccine in hemodialysis patients. J Med Virol 79:1176–1179Google Scholar
  61. 61.
    Poduval RD, Hammes MD (2003) Tuberculosis screening in dialysis patients—is the tuberculin test effective? Clin Nephrol 59:436–440Google Scholar
  62. 62.
    Winthrop KL, Nyendak M, Calvet H, Oh P, Lo M, Swarbrick G et al (2008) Interferon-gamma release assays for diagnosing mycobacterium tuberculosis infection in renal dialysis patients. Clin J Am Soc Nephrol 3:1357–1363Google Scholar
  63. 63.
    Pencheva VP, Petrova DS, Genov DK et al (2015) Risk factors for lung diseases after renal transplantation. J Res Med Sci 20(12):1127–1132Google Scholar
  64. 64.
    Canet E, Osman D, Lambert J et al (2011) Acute respiratory failure in kidney transplant recipients: a multicenter study. Crit Care 15(2):R91Google Scholar
  65. 65.
    Pencheva V, Petrova D, Genov D et al (2014) Pulmonary complications as a cause of death after renal transplantation. Open J Intern Med 4:41–46Google Scholar
  66. 66.
    Zeyneloglu P (2015) Respiratory complications after solid-organ transplantation. Exp Clin Transpl 13(2):115–125Google Scholar
  67. 67.
    Kupeli E, Ulubay G, Colak T et al (2011) Pulmonary complications in renal recipients after transplantation. Transpl Proc 43(2):551–553Google Scholar
  68. 68.
    Splendiani G, Cipriani S, Tisone G et al (2005) Infectious complications in renal transplant recipients. Transpl Proc 37(6):2497–2499Google Scholar
  69. 69.
    Fishman JA (2007) Infection in solid-organ transplant recipients. N Engl J Med 357:2601–2614Google Scholar
  70. 70.
    Sasaki T, Nakamura W, Inokuma S et al (2016) Characteristic features of tacrolimus-induced lung disease in rheumatoid arthritis patients. Clin Rheumatol 35(2):541–545Google Scholar
  71. 71.
    Boddana P, Webb LH, Unsworth J et al (2011) Hypogammaglobulinemia and bronchiectasis in mycophenolate mofetil-treated renal transplant recipients: an emerging clinical phenomenon? Clin Transpl 25(3):417–419Google Scholar
  72. 72.
    Gorgan M, Bockorny B, Lawlor M et al (2013) Pulmonary hemorrhage with capillaritis secondary to mycophenolate mofetil in a heart-transplant patient. Arch Pathol Lab Med 137(11):1684–1687Google Scholar
  73. 73.
    Tomei P, Masola V, Granata S et al (2016) Everolimus-induced epithelial to mesenchymal transition (EMT) in bronchial/pulmonary cells: when the dosage does matter in transplantation. J Nephrol 29:881Google Scholar
  74. 74.
    Solazzo A, Botta C, Nava F et al. (2016) Interstitial lung disease after kidney transplantation and the role of Everolimus. Transpl Proc 48(2):349–351Google Scholar
  75. 75.
    Faubel S, Edelstein CL (2016 Jan) Mechanisms and mediators of lung injury after acute kidney injury. Nat Rev Nephrol 12(1):48–60Google Scholar
  76. 76.
    Dushianthan A, Grocott MP, Postle AD, Cusack R (2011) Acute respiratory distress syndrome and acute lung injury. Postgrad Med J 87(1031):612–622Google Scholar
  77. 77.
    Srisawat N, Kellum JA (2011) Acute kidney injury: definition, epidemiology, and outcome. Curr Opin Crit Care 17(6):548–555Google Scholar
  78. 78.
    Koyner JL, Murray PT (2010) Mechanical ventilation and the kidney. Blood Purif 29:52–68Google Scholar
  79. 79.
    Pannu N et al (2004) Effect of mechanical ventilation on the kidney. Best Pract Res Clin Anaesthesiol 18:189–203Google Scholar

Copyright information

© Italian Society of Nephrology 2018
corrected publication 2019

Authors and Affiliations

  1. 1.Division of PulmonologyS. Anna HospitalComoItaly
  2. 2.Biomedical Department of Internal and Specialist MedicineUniversity of PalermoPalermoItaly
  3. 3.Chair of GeriatricsUniversity Campus Bio-MedicoRomeItaly
  4. 4.University of InsubriaVareseItaly
  5. 5.Division of Pulmonary RheabilitationMaugeri Care and Research Institute, IRCCSTradateItaly

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