Acute Kidney Function Declines in the Context of Decongestion in Acute Decompensated Heart Failure.
OBJECTIVES
This study aimed to examine whether incorporation of a comprehensive set of measures of decongestion modifies the association of acute declines in kidney function with outcomes.


BACKGROUND
In-hospital acute declines in kidney function occur in approximately 20% to 30% of patients admitted with acute decompensated heart failure (ADHF) and may be associated with adverse outcomes.


METHODS
Using data from EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan), we used multivariable Cox regression models to evaluate the association between in-hospital changes in estimated glomerular filtration rate (eGFR) with death and a composite outcome of cardiovascular death and hospitalization for heart failure. We evaluated eGFR declines within the context of changes in markers of volume overload including b-type natriuretic peptide (BNP), N-terminal prohormone of B-type natriuretic peptide (NT-proBNP), and weight, as well as changes in measures of hemoconcentration including hematocrit, albumin, and total protein.


RESULTS
Among 3,715 patients over a median follow-up of 9.9 months, every 30% decline in eGFR was associated with higher risk of both death (hazard ratio [HR]: 1.19; 95% confidence interval [CI]: 1.07 to 1.31) and the composite outcome (HR: 1.09; 95% CI: 1.01 to 1.18) in adjusted models. The acute decline in eGFR was no longer associated with higher risk of either outcome as long as there was evidence of decongestion, either by declines in BNP, NT-proBNP, or weight or by increases in hematocrit, albumin or total protein. Interaction testing between decline in eGFR and changes in hematocrit, albumin, and total protein was statistically significant (p interaction of <0.01 for death and p interaction of ≤0.01 for composite for all 3 biomarkers). Interaction between change in eGFR and changes in BNP (p interaction = 0.07 for death; p interaction = 0.08 for composite), NT-proBNP (p interaction = 0.15 for death; p interaction = 0.18 for composite) and weight (p interaction = 0.13 for death; p interaction = 0.19 for composite) did not meet statistical significance.


CONCLUSIONS
Overall, acute declines in eGFR are associated with adverse outcomes, with evidence of modification by changes in markers of decongestion, suggesting that they are no longer associated with adverse outcomes if these markers are concomitantly improving.
['McCallum|Wendy|W|', 'Tighiouart|Hocine|H|', 'Testani|Jeffrey M|JM|', 'Griffin|Matthew|M|', 'Konstam|Marvin A|MA|', 'Udelson|James E|JE|', 'Sarnak|Mark J|MJ|']
D058186:Acute Kidney Injury D000368:Aged D065092:Antidiuretic Hormone Receptor Antagonists D015415:Biomarkers D005260:Female D005919:Glomerular Filtration Rate D006333:Heart Failure D006801:Humans D007668:Kidney D008297:Male D008875:Middle Aged D020097:Natriuretic Peptide, Brain D011379:Prognosis D013318:Stroke Volume D000077602:Tolvaptan
decongestion hemoconcentration cardiorenal worsening renal function