The cardiorenal anemia syndrome. Congestive heart failure (CHF) is a cause and consequence of CKD. First, CHF inflames the heart, liver, and vasculature, creating an influx of circulating cytokines that depress erythropoiesis and perturb iron metabolism . Second, CHF directly induces kidney damage, in which GFR can deteriorate by as much as one mL/min/month [45–47]. In response to reduced cardiac output, blood pressure (and renal perfusion) is maintained by activation of the renin-angiotensin-aldosterone system. Angiotensin II-mediated renal vasoconstriction and increased metabolic demands of the kidney result in renal ischemia and ultimately tubular cell death . Renal cell death in turn hastens anemia through loss of endocrine function. In addition, aldosterone-induced salt and water retention leads to an increased pre-load on the heart, which increases its rate in an attempt to increase output.