Prognostic implications of renal dysfunction in patients hospitalized with heart failure: data from the last decade of clinical investigations

Abstract

Numerous studies over the last decade have demonstrated that renal dysfunction and worsening renal function (WRF) are common in patients hospitalized for heart failure (HHF) and appear to be associated with poor in-hospital and post-discharge outcomes. Unfortunately, its etiology has not been completely understood, and its prediction during hospitalization remains challenging. The evaluation of renal impairment during hospitalization should take into consideration the underlying renal substrate (e.g., predisposing clinical comorbidities such as diabetes and hypertension), initiating mechanisms (e.g., in-hospital therapies such as diuretics), and amplifying factors (neurohormonal and hemodynamic profile changes). Various patterns of WRF may have different prognostic implications and may require different therapeutic approaches. WRF may be initially classified by duration (transient vs. persistent) and by etiology (elevated venous pressures vs. arterial underfilling). Other critical contributing factors during hospitalization include progressive left ventricular dysfunction, neurohormonal activation, and medications. Transient WRF as a result of aggressive therapy targeting congestion may not be associated with poor outcomes. Persistent WRF seen in patients with severe hemodynamic derangements may be associated with poor post-discharge prognosis. Future investigations must clarify the pathophysiological correlates of various patterns of WRF. To date, there is an unmet clinical need to achieve adequate control over congestion while preserving renal function in HHF patients. Thus, the aim of this review is to provide an in-depth and critical interpretation of the available data on the prognostic importance of RD and WRF during hospitalization in an effort to improve HF management.

The potential role of NT-proBNP in screening for and predicting prognosis in heart failure: a survival analysis

“…Only 3% of participants were non-white which may not fully reflect the ethnic diversity of the UK population and NT-proBNP levels may vary depending on ethnicity. Renal function was not recorded in this study therefore we were unable to assess the effect of renal impairment on mortality 13. A cut-off of 150 pg/mL was chosen to represent a raised level of NT-proBNP in the substudy however debate exists around the optimal cut-off level for NT-proBNP 14…”

Decongestive Therapy and Renal Function in Acute Heart Failure

“…5,6 Although the threshold for the degree of WRF and outcomes remains poorly defined, an increase in serum creatinine of ≥0.3 mg/dL has also clearly been associated with worse outcomes. 7 Recently, several retrospective analyses from completed trials have suggested that it may be important to consider the time course of WRF and the relationship of WRF to the degree of decongestion achieved, but even in those analyses, the best outcomes are clearly in those patients who achieve clinical decongestion while preserving renal function. [8][9][10] Until a prospective trial clearly establishes that any form of WRF is safe during treatment of AHF, it is reasonable to assume that the goal of treatment should be adequate clinical decongestion without causing renal dysfunction (or worsening it if already present).…”

Targeting the Kidney in Acute Heart Failure: Can Old Drugs Provide New Benefit?

“…5 A meta-analysis of 16 studies characterizing the association between renal impairment and mortality in HF patients indicated that one-year mortality increased incrementally across the range of renal function with a seven percent increase in risk for every 10 ml/min decrease in GFR. 6 As recently reviewed, 7 numerous more recent studies have confirmed the association of renal dysfunction with adverse short- and long-term outcomes in ADHF, an association which appears equally robust in ADHF patients with reduced (HFrEF) or preserved (HFpEF) ejection fraction (EF).…”