Association of left ventricular ejection fraction with worsening renal function in patients with acute heart failure: insights from the RELAX‐AHF‐2 study

Abstract

Aims Whether risk of worsening renal function (WRF) during acute heart failure (AHF) hospitalization or the association between in‐hospital WRF and post‐discharge outcomes vary according to left ventricular ejection fraction (LVEF) is uncertain. We assessed incidence of WRF, factors related to its development and impact of WRF on post‐discharge outcomes across the spectrum of LVEF in patients enrolled in RELAX‐AHF‐2. Methods and results A total of 6112 patients who had LVEF measured on admission and renal function determined prospectively during hospitalization were included. WRF, defined as a rise in serum creatinine ≥0.3 mg/dL from baseline through day 5, occurred in 1722 patients (28.2%). Incidence increased progressively from lowest to highest LVEF quartile (P < 0.001). After baseline adjustment, WRF risk in Q4 (LVEF >50%) remained significantly greater than in Q1 (LVEF ≤29%; hazard ratio 1.2, 95% confidence interval 1–1.43; P = 0.050). Age and comorbidity burden including chronic kidney disease increased as LVEF increased. Neither admission haemodynamic abnormalities, extent of diuresis during hospitalization nor residual congestion explained the increased incidence of WRF in patients with higher LVEF. Serelaxin treatment and diuretic responsiveness were associated with reduced risk of WRF in all LVEF quartiles. WRF in patients in the upper three LVEF quartiles increased risk of post‐discharge events. Conclusions Worsening renal function incidence during AHF hospitalization increases progressively with LVEF. Greater susceptibility of patients with higher LVEF to WRF appears more related to their advanced age and worse underlying kidney function rather than haemodynamic or treatment effects. WRF is associated with increased risk of post‐discharge events except in patients in the lowest LVEF quartile.

January 2021 at a glance: focus on sex differences, acute heart failure and exercise capacity

“…In an analysis of the Relaxin in Acute Heart Failure‐2 (RELAX‐AHF‐2) trial, worsening renal function (WRF), defined as a rise in serum creatinine ≥0.3 mg/dL, occurred in 28.2% of patients within the first 5 days of an acute HF hospitalization. The risk of WRF was higher in patients with a higher left ventricular ejection fraction (LVEF) and WRF was associated with an increased risk of death in WRF patients in the upper three LVEF quartiles 11 …”

Different Renal Function Patterns in Patients With Acute Heart Failure: Relationship With Outcome and Congestion

“…Some studies report that WRF is a detrimental factor in HF deterioration and outcome. Other authors described this status as a simple condition linked to decongestion therapy and the high loop diuretic amount administered during the acute phase (7)(8)(9)(10). Alternatively, an increased neurohormonal overdrive and altered renal blood flow redistribution may be implicated.…”

Worsening renal function after diuresis among heart failure patients with preserved ejection fraction: a dilemma to heart failure management. Letter regarding the article ‘Association of left ventricular ejection fraction with worsening renal function in patients with acute heart failure: insights from the RELAX‐AHF‐2 study’

“…HFpEF patients tend to be older, obese, and have multiple comorbidities, often resulting in higher rates of hospital admissions, prolonged hospitalizations, and significant post-discharge events. 1,2 We read with great interest the study by Feng et al 3 which investigated potential mechanism(s) underlying these challenges. In this study, specifically among HFpEF patients with renal insufficiency, Feng et al found that advanced age and baseline kidney function are two risk factors that may portend the development of worsening renal function (WRF) while hospitalized.…”

“…HFpEF patients tend to be older, obese, and have multiple comorbidities, often resulting in higher rates of hospital admissions, prolonged hospitalizations, and significant post‐discharge events 1,2 . We read with great interest the study by Feng et al 3 . which investigated potential mechanism(s) underlying these challenges.…”

“…found that advanced age and baseline kidney function are two risk factors that may portend the development of worsening renal function (WRF) while hospitalized. More importantly, increased risk of cardiovascular death and hospital readmissions occurred within 180 days post‐discharge among patients who developed WRF during the index hospitalization 3 . In our practice, HF patients have been placed in our observation units under aggressive diuresis protocols with most patients being discharged within 24 h. However, a significant number of HFpEF patients with chronic renal insufficiency will need extended inpatient treatment due to their WRF after diuresis 4 .…”