Worsening renal function during decongestion among patients hospitalized for heart failure: Findings from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial

Fudim, Marat; Loungani, Rahul S.; Doerfler, Shannon M.; Coles, Adrian; Greene, Stephen J.; Cooper, Lauren B.; Fiuzat, Mona; O’Connor, Christopher M.; Rogers, Joseph G.; Mentz, Robert J.

doi:10.1016/j.ahj.2018.07.019

Cited by 48 publications

(29 citation statements)

References 29 publications

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“…To further evaluate the safety of RASB use in those with renal insufficiency or worsening renal failure (WRF) in future studies, it will be important to concomitantly assess clinical congestion. As WRF may be observed in ADHF, adverse outcomes seem to be driven by those who remain congested . Thus, elucidating the cause of renal insufficiency in relation to congestion may distinguish the effects of RASB therapy.…”

Section: Discussionmentioning

confidence: 99%

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Implications of renin‐angiotensin‐system blocker discontinuation in acute decompensated heart failure with systolic dysfunction

Darden

Drazner

Mullens

et al. 2019

Clinical Cardiology

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Background Renin‐angiotensin‐system blockers (RASB) improve clinical outcomes in patients with chronic heart failure with reduced fraction; however, there remains ambiguity whether RASB therapy should be continued during the treatment of acute decompensated heart failure (ADHF). Hypothesis In comparison to patients with RASB use, RASB discontinuation in ADHF will be associated with worsening renal function, hypotension, and adverse long‐term clinical outcomes. Methods Patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization (ESCAPE) trial were separated into four groups based on RASB use at baseline and discharge: continuation (n = 316), discontinuation (n = 21), initiation (n = 42), and nonuse (n = 23). Post‐discharge outcomes were validated in an independent ADHF cohort admitted to the Cleveland Clinic (n = 253). Results RASB discontinuation and nonuse were associated with higher serial creatinine and blood urea nitrogen levels than RASB continuation or initiation (P < .001 for both), but not with serial potassium and systolic blood pressure measurements. No other clinical parameter changes were significant. In comparison to RASB continuation, RASB discontinuation and nonuse was associated with ~75% increased risk of a 180‐day composite of death, transplant, or rehospitalization (HR 1.87, 95% CI 1.09‐3.20, P = 0.02 and HR 1.72, CI 1.04‐2.82, P = .03, respectively). Post‐discharge outcomes were similar in the validation cohort. Conclusion Compared to RASB continuation, RASB discontinuation and nonuse were associated with higher baseline and serial creatinine levels during treatment for ADHF, but not with changes in SBP and potassium levels. Furthermore, RASB discontinuation and nonuse in ADHF were associated with an increased risk of adverse clinical outcomes.

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Section: Discussionmentioning

confidence: 99%

“…As WRF may be observed in ADHF, adverse outcomes seem to be driven by those who remain congested. 21,22 15 Whether continuing or initiating RASB therapy in those who are congested and normotensive with elevated creatinine warrants further investigation.…”

Section: Discussionmentioning

confidence: 99%

Implications of renin‐angiotensin‐system blocker discontinuation in acute decompensated heart failure with systolic dysfunction

Darden

Drazner

Mullens

et al. 2019

Clinical Cardiology

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“…Small fluctuations in serum creatinine levels in the setting of aggressive diuresis and/or institution of goal-directed therapies for HF likely represented benign hemodynamic changes rather than actual tubular injury or necrosis. Along the same lines, Fudim et al [5] showed that WRF did not carry the same negative prognostic value when effective decongestion at discharge was achieved, as compared to persistent congestion with WRF in a post hoc analysis of the Evaluation Study of congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial across several methods of assessing congestion. Similar findings were also confirmed in a post hoc analysis of the Placebo-Controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized With Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function (PROTECT) trial, wherein the HR for WRF on 30-day death or heart failure hospitalization was 1.49 (95% CI 1.06–2.09) in significantly congested patients compared to those without congestion [6].…”

Section: Decongestion In Acute Heart Failure: “Drier” Is Better In Tymentioning

confidence: 98%

Key Updates in Cardio-Nephrology from 2018: Springboard to a Bright Future

2019

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“…11,12 The prognostic significance of such changes in renal function during treatment of decompensated heart failure has been debated in different studies. 13,14 Pathophysiology of acute kidney injury in decompensated heart failure (cardiorenal syndrome)…”

Section: Prevalence and Adverse Association Of Chronic Kidney Diseasementioning

confidence: 99%

“…This is supported by studies demonstrating that congestion at discharge, irrespective of in hospital AKI, confers a worse prognosis than in those patients who have been adequately off-loaded of fluid even if they do have AKI at discharge. 14 The use of UF in patients with acute decompensated heart failure (ADHF) held promise as a key method of decongestion after the UNLOAD trial showed improved outcomes and fewer readmissions with UF. 25 However, UF as a regular treatment fell out of favour after the CARESS-HF study showed a higher rise in serum creatinine (20.3 μmol/L vs −3.5 μmol/L; p=0.003) without a significant difference in weight reduction (12.6 kg vs 12.1 kg; p=0.58) or symptoms in the UF group compared to the pharmacologic therapy group.…”

Section: Cme: Renal Medicinementioning

confidence: 99%

Heart failure and acute renal dysfunction in the cardiorenal syndrome

et al. 2020

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Just under 1 million people in the UK have symptomatic heart failure. Decompensated heart failure is associated with a particularly poor prognosis with in-hospital mortality at around 10%. Over the last 30 years renin-angiotensinaldosterone system antagonists have been shown to have incremental benefi t on improved quality of life, reduced hospitalisation and mortality rates in those with heart failure with reduced ejection fraction. Concomitant chronic kidney disease and 'acute kidney injury' are common and associated with adverse outcomes. In patients with decompensated heart failure, congestion is a key driver of deterioration in renal function. Decongestion is fundamental to successful management. Yet it is not uncommon to see prognostically important medication (such as angiotensin converting enzyme inhibitors and mineralocorticoid antagonists) inappropriately stopped, along with under-diuresis of the patient. This leaves the patient still in a state of congestion without the prognostic medication at discharge, with resultant adverse outcome. The British Society for Heart Failure and the Renal Association have produced consensus guidance to help guide management in a more consistent fashion based on heart failure classifi cation, whether the patient is congested and the degree of renal impairment. Early heart failure specialist review is associated with improved patient outcomes.

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Worsening renal function during decongestion among patients hospitalized for heart failure: Findings from the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) trial

Cited by 48 publications

References 29 publications

Implications of renin‐angiotensin‐system blocker discontinuation in acute decompensated heart failure with systolic dysfunction

Implications of renin‐angiotensin‐system blocker discontinuation in acute decompensated heart failure with systolic dysfunction

Key Updates in Cardio-Nephrology from 2018: Springboard to a Bright Future

Heart failure and acute renal dysfunction in the cardiorenal syndrome

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