Renal function and acute heart failure outcome

Basal natriuresis as a predictor of diuretic resistance and clinical evolution in acute heart failure

BACKGROUND

Some clinical guidelines recommend serial measurement of natriuresis to detect diuretic resistance (DR) in acute heart failure (AHF) patients, but it adds complexity to the management.

OBJECTIVES

To correlate a single measurement of basal natriuresis (BN) on admission with the development of DR and clinical evolution in AHF hospitalized patients.

METHODS

Prospective and multicenter study included AHF hospitalized patients, without shock or creatinine >2.5mg%. Patients received 40mg of intravenous furosemide on admission, then BN was measured, and diuretic treatment was guided by protocol. BN was considered low if <70 meq/L. DR was defined as the need of furosemide >240mg/day, tubular blockade (TB), hypertonic saline solution (HSS) or renal replacement therapy (RRT). In-hospital cardiovascular (CV) mortality, CV mortality and AHF readmissions at 60-day post-discharge were evaluated.

RESULTS

157 patients were included. BN was low in 22%. DR was development in 19% (12.7% furosemide >240mg/day, 8% TB, 4% RRT). Low NB was associated with DR (44% vs 12%; p 0.0001), persistence of congestion (26.5% vs 11.4%; p 0.05), furosemide >240 mg/day (29% vs 8%; p 0.003), higher cumulative furosemide dose at 72 hours (220 vs 160mg; p 0.0001), TB (20.6 vs 4.9%; p 0.008), RRT (11.8 vs 1.6%; p 0.02), worsening of AHF (27% vs 9%; p 0.01), inotropes use (21% vs 7%; p 0.48), respiratory assistance (12% vs 2%; p 0.02) and a higher in-hospital CV mortality (12% vs 4%; p 0.1). No association was demonstrated with post-discharge endpoints.

CONCLUSIONS

In AHF patients, low BN was associated with DR, persistent congestion, need for aggressive decongestion strategies, and worse in-hospital evolution.

Blood urea nitrogen to serum albumin ratio as a new indicator of disease severity and prognosis in idiopathic pulmonary artery hypertension

BACKGROUND

Emerging evidence has shown that the blood urea nitrogen to serum albumin ratio (BAR) is associated with the severity and prognosis of heart failure. However, its role in idiopathic pulmonary arterial hypertension (IPAH) remains unclear. This study investigated the associations between BAR and functional status, echocardiographic findings, hemodynamics, and long-term outcomes among patients with IPAH.

METHODS

This study included consecutive patients who underwent right heart catheterization (RHC) and were diagnosed with IPAH between January 2013 and January 2018 at Fuwai Hospital. The primary outcome was the worsening of clinical symptoms. Spearman correlation coefficients were used to evaluate the association between the BAR and established markers of IPAH severity. Receiver operating characteristic (ROC) curve analysis was used to determine BAR's optimal cut-off and predictive performance. Kaplan-Meier analysis and Cox proportional hazard models assessed the relationship between BAR and clinical worsening.

RESULTS

A total of 340 patients with IPAH were included in this study. BAR correlated with well-validated variables that reflected the severity of IPAH, such as World Health Organization functional class, 6-min walk distance, N-terminal pro-brain natriuretic peptide (NT-proBNP) level, mixed venous oxygen saturation, and cardiac index. Kaplan-Meier curves indicated that patients with BAR＞3.80 had a significantly higher clinical worsening rate (log-rank test, P < 0.001) than those with BAR≤3.80. Multivariate Cox analysis showed that BAR could independently predict clinical worsening [hazard ratio(HR):2.642, 95 % confidence interval (CI):1.659-4.208, P < 0.001]. In addition, BAR provided additional predictive value for the European Society of Cardiology (ESC)/European Respiratory Society (ERS) risk assessment score.

CONCLUSIONS

BAR reflects disease severity and is independently associated with the prognosis of patients with IPAH.

Impact of worsening renal function detected at emergency department arrival on acute heart failure short-term outcomes

BACKGROUND AND IMPORTANCE

Deterioration of renal function with respect to baseline during an acute heart failure (AHF) episode is frequent, but impact on outcomes is still a matter of debate.

OBJECTIVE

To investigate the association of creatinine deterioration detected at emergency department (ED) arrival and short-term outcomes in patients with AHF.

DESIGN

Secondary analysis of a large multipurpose registry.

SETTINGS AND PARTICIPANTS

Patients with AHF were diagnosed in 10 Spanish ED for whom a previous baseline creatinine was available.

EXPOSURE

Difference between creatinine at ED arrival and at baseline was calculated (∂-creatinine).

OUTCOME MEASURES AND ANALYSIS

Primary outcome was 30-day all-cause death, and secondary outcomes were inhospital all-cause death, prolonged hospitalization (>7 days) and 7-day postdischarge adverse events. Associations between ∂-creatinine and outcomes were explored using logistic regression by restricted cubic spline (RCS) curves and expressed as odds ratio (OR) with 95% confidence interval (CI), taking ∂-creatinine = 0 mg/dl as reference. Curves were adjusted by age, sex, comorbidities, patient baseline status, chronic treatments, and vitals and laboratory results at ED arrival. Interactions for the primary outcome also were investigated.

MAIN RESULTS

We analyzed 3036 patients (median age = 82 years; IQR = 75-87; women = 55%), with ∂-creatinine ranged from -0.3 to 3 mg/dl. The 30-day mortality was 11.6%. Increments of ∂-creatinine were associated with progressive increase in risk of 30-day death, although adjustment attenuated this association: ∂-creatinine of 0.3/1/2/3 mg/dl were, respectively, associated with adjusted OR of 1.41 (1.02-1.95), 1.69 (1.02-2.80), 1.46 (0.56-3.80) and 1.27 (0.27-5.83). Distinctively significant higher risk was found for patients over 80 years old, female, nondiabetic, functionally disabled and on digoxin therapy. With respect to secondary outcomes, inhospital mortality was 8.1%, prolonged hospitalization was 33.6% and 7-day postdischarge adverse event was 9.7%. Inhospital death steadily increased with increments in ∂-creatinine [from 1.50 (1.04-2.17) with ∂-creatinine = 0.3 to 3.78 (0.78-18.3) with ∂-creatinine = 3], as well as prolonged hospitalization did [from 1.41 (1.11-1.77) to 2.24 (1.51-3.33), respectively]. Postdischarge adverse events were not associated with ∂-creatinine.

CONCLUSION

WRF detected at ED arrival has prognostic value in AHF, being associated with increased risk of death and prolonged hospitalization. These associations showed different patterns of risk but, remarkably, risk started with increments as low as 0.3 mg/dl.

Age- and sex-specific reference intervals for blood urea nitrogen in Chinese general population

Blood urea nitrogen (BUN) is a nitrogenous end product of protein metabolism. This study aims to explore the age- and sex-specific distribution of BUN among healthy Chinese adults. A total of 24,006 BUN values from healthy adults (14,148 males and 9858 females) were included in the cross-sectional study. Males had a higher median BUN value compared to females (4.6 mmol/L vs. 4.1 mmol/L). BUN values showed a positive correlation with body mass index (BMI), cholesterol, and blood sugar (P < 0.0001). However, eGFR showed a negative correlation with the BUN reference value (P < 0.0001) in both sexes. Multiple linear regression analysis confirmed that the positive associations of BUN levels and age were statistically significant after adjusting confounding factors (P < 0.001). Thus, the serum BUN values increased by 0.21 mmol/L for males and 0.282 mmol/L for females per 10 years. The BUN values corresponding to the 1st, 2.5th, 50th, 97.5th, and 99th percentiles for any specific age in both sex were also calculated. These results indicate that the serum BUN reference value is significantly affected by age and gender, and thus, its interpretation is age- and sex-dependent.

The CRAS-EAHFE study: Characteristics and prognosis of acute heart failure episodes with cardiorenal-anaemia syndrome at the emergency department

BACKGROUND

The coexistence of other comorbidities confers poor outcomes in patients with acute heart failure. Our aim was to determine the characteristics of patients with acute heart failure and cardiorenal anaemia syndrome and the relationship between renal dysfunction and anaemia, alone or combined as cardiorenal anaemia syndrome, on short-term outcomes.

METHODS

We analysed the Epidemiology of Acute Heart Failure in Emergency Departments registry (cohort of patients with acute heart failure in Spanish emergency departments). Renal dysfunction was defined by an estimated glomerular filtration rate <60 ml/min/m², anaemia by haemoglobin values <12/<13 g/dl in women/men, and cardiorenal anaemia syndrome as the presence of both. Comparisons were made according to cardiorenal-anaemia syndrome positive (CRAS+) with respect to the rest of patients (CRAS-) and according the presence of renal dysfunction (RD+) and anaemia (A+), (alone, RD+/A-, RD-/A+) or in combination (RD+/A+; i.e. CRAS+) with respect to patients without renal dysfunction and anaemia (RD-/A-). The primary outcome was 30-day mortality, and the secondary outcomes were need for admission, prolonged hospitalisation (>10 days), in-hospital mortality during the index event, and reconsultation and the combination of 30-day post-discharge reconsultation/death. These short-term outcomes were compared and adjusted for differences among groups.

RESULTS

Of the 13,307 patients analysed, CRAS+ (36.4%) was associated with older age, multiple comorbidities, chronic use of loop diuretics, oedemas and hypotension. The 30-day mortality in CRAS+ was greater than in CRAS- (hazard ratio = 1.46, 95% confidence interval = 1.26-1.68) and RD-/A- (hazard ratio = 1.83, 95% confidence interval = 1.46-2.28) control groups. The mortality level was also higher in RD+/A- (hazard ratio = 1.40, 95% confidence interval = 1.10-1.78) and higher, but not statistically significant, in RD-/A+ (hazard ratio = 1.28, 95% confidence interval = 0.99-1.63) with respect to RD-/A-. All of the secondary outcomes, when related to CRAS- and RD-/A- control groups, were worse for CRAS+ and to a lesser extent, RD+/A-, being more rarely observed in RD-/A+.

CONCLUSIONS

Cardiorenal anaemia syndrome in acute heart failure is related to greater mortality and worse short-term outcomes, and the impact of renal dysfunction and anaemia seems to be additive.

Acute heart failure and adverse events associated with the presence of renal dysfunction and hyperkalaemia. EAHFE- renal dysfunction and hyperkalaemia

OBJECTIVE

To study the outcomes of patients with acute heart failure (AHF) presenting renal dysfunction (RD) or hyperkalaemia (Hk) alone or in combination.

METHOD

We analysed the data of the EAHFE registry, a multicentre, non interventionist cohort with prospective follow-up of patients with AHF. Four groups were defined based on the presence or not of RD or Hk alone or in combination. The primary endpoint was 30-day all-cause mortality.

RESULTS

A total of 11,935 of the 13,791 patients included in the EAHFE registry were analysed. Of these, 5088 (42.6%) did not have RD or Hk (NoRD-NoHk), 150 (1.3%) had no RD but had Hk (NoRD-Hk), 6012 (50.4%) had RD but not Hk (RD-NoHk) and 685 (5.7%) had both RD and Hk (RD-Hk). Thirty-day all-cause mortality was greatest in the RD-Hk group with an adjusted Hazard Ratio (HR) of 2.44 (confidence interval 95% [CI95%] 1.67-3.55; p < 0.001) and in the RD-NoHk group with an adjusted HR of 1.34 (CI95% 1.04-1.71; p = 0.022). There were no significant differences in in-hospital mortality and reconsultation at 30 days for HF. For the combined endpoint of 30-day all-cause mortality the adjusted HR was 1.33 (CI95% 1.04-1.70); (p = 0.021) for the RD-Hk group.

CONCLUSIONS

The association of 30-day all-cause mortality with the presence of RD and Hk in patients presenting AHF at admission is greater than in those without this combination.

Prediction of all-cause mortality with hypoalbuminemia in patients with heart failure: a meta-analysis

Objective: The prognostic utility of serum albumin level for mortality in heart failure patients has received considerable attention. This meta-analysis sought to examine the prognostic significance of hypoalbuminemia for prediction of all-cause mortality in patients with heart failure. Materials and methods: Pubmed and Embase databases were systematically searched up to 10 March 2019 to identify eligible studies. Epidemiological studies reporting a multivariable-adjusted risk estimate of all-cause mortality associated with hypoalbuminemia in acute or chronic heart failure patients were included. Results: Nine studies from 10 articles involving 16,763 heart failure patients were included in the final analysis. Hypoalbuminemia was associated with an increased in-hospital mortality (risk ratio [RR] 4.90; 95% confidence interval [CI] 2.96-8.10) and long-term all-cause mortality (RR 1.75; 95% CI 1.35-2.27) in acute heart failure patients. Chronic heart failure patients with hypoalbuminemia exhibited a 3.5-fold (95% CI 1.29-9.73) higher risk for long-term all-cause mortality. Conclusions: Hypoalbuminemia is possibly an independent predictor of all-cause mortality in patients with acute or chronic heart failure. However, the current findings should be further confirmed in future prospective studies. Moreover, future well-designed randomized controlled trials would be required to investigate whether correcting hypoalbuminemia in heart failure patients has potential to improve survival outcome.

Prognostic value of serum uric acid in patients with acute heart failure: A meta-analysis

BACKGROUND

Conflicting results have been reported on the prognostic significance of serum uric acid (SUA) in patients with acute heart failure (AHF). This meta-analysis aimed to determine the prognostic significance of SUA level in patients with AHF.

METHODS

We made a comprehensive literature search in Pubmed and Embase databases from inception to April 6, 2018. All available observational studies or post hoc analysis of randomized controlled trial that evaluated the prognostic value of SUA level in patients with AHF were eligible. Outcome of interests were all-cause mortality and the combined endpoint of death or readmission. Prognostic values of SUA level were summarized as higher vs lower SUA category or per 1 mg/ml SUA rise.

RESULTS

Ten studies involving 12,854 AHF patients were identified and analyzed. AHF patients with the highest SUA level had an increased risk of all-cause mortality (risk ratio [RR] 1.43; 95% confidence intervals [CI] 1.31-1.56) and combined endpoint of death or readmission (RR 1.68; 95% CI 1.33-2.13) after adjusting potential variables. In addition, per 1 mg/ml SUA rise significantly increased by 11% and 12% higher risk all-cause mortality and combined endpoint of death or readmission, respectively. A leave out 1 study sensitivity analysis confirmed the reliability of the pooling effect sizes.

CONCLUSION

This meta-analysis indicates that elevated SUA level independently predicts all-cause mortality and the combined endpoint of death or readmission in AHF patients. Measurement of SUA level may improve risk stratification of adverse outcomes in these patients.

The association among biomarkers of renal and heart function in patients with heart failure: the role of NGAL

AIM

The NGAL is a biomarker of renal injury associated with the progression of heart failure (HF). We examine the association of NGAL with galectin-3 in patients with chronic HF.

METHODS

We consecutively enrolled 115 subjects with stable ischemic HF of reduced ejection fraction. Serum levels of galectin-3, b-type natriuretic peptide and NGAL were measured.

RESULTS

NGAL levels were positively correlated with galectin-3 (rho = 0.26; p = 0.04) and b-type natriuretic peptide levels (rho = 0.30; p = 0.005) and inversely correlated with ejection fraction (rho = -0.31; p = 0.02) and creatinine clearance levels. The NGAL was independently associated with galectin-3 levels.

CONCLUSION

A positive correlation between NGAL and galectin-3 in HF patients was found, revealing a potential association between renal injury and myocardial fibrosis and remodeling in HF.