Acute Kidney Injury Recovery Status Predicts Mortality and Cardiorenal Outcomes in Patients Admitted with Acute Decompensated Heart Failure

Overview

Journal Open Heart

Publisher BMJ Publishing Group

Specialty Cardiology & Vascular Diseases

Date 2025 Jan 5

PMID 39756821

Authors

Sumita Barua

Sanjay Chavali

Albert Vien

Shehane Mahendran

David Makarious

Phillip Lo

Kirsty Pringle

James Chong

Kavitha Muthiah

Christopher Hayward

Affiliations

Soon will be listed here.

Abstract

Background: Acute kidney injury (AKI) in the context of acute decompensated heart failure (ADHF) encompasses a broad spectrum of phenotypes with associated disparate outcomes. We evaluate the impact of 'ongoing AKI' on prognosis and cardiorenal outcomes and describe predictors of 'ongoing AKI'.

Methods: A prospective multicentre observational study of patients admitted with ADHF requiring intravenous furosemide was completed, with urinary angiotensinogen (uAGT) measured at baseline. AKI was defined using Kidney Disease Improving Global Outcomes (KDIGO) AKI criteria. AKI recovery status was defined as 'no AKI', 'recovered AKI' or 'ongoing AKI' based on renal function at hospital discharge. Event-free survival analysis was performed to predict death and cardiorenal outcomes at hospital discharge and 6-month follow-up. Multinomial logistic regression was performed to identify predictors of ongoing AKI. Multiclass receiver operator curve analysis was performed to evaluate the relationship between renin-angiotensin system (RAS) blockers and uAGT in predicting ongoing AKI.

Results: Among 271 enrolled patients, 121 (44.6%) patients developed AKI, of whom 62 patients had ongoing AKI. Ongoing AKI was associated with increased risk of death (HR 6.89, p<0.001), in-hospital end-stage kidney disease (HR 44.39, p<0.001), 6-month composite of death, transplant, left ventricular assist device and heart failure hospitalisation (HR 3.09, p<0.001), and 6-month composite major adverse kidney events (HR 5.71, p<0.001). Elevated baseline uAGT levels, chronic beta-blocker and thiazide diuretic therapy, and lack of RAS blocker prescription at recruitment were associated with ongoing AKI. While uAGT levels were lower with RAS blocker prescription, in patients with ongoing AKI, uAGT levels were elevated regardless of RAS blocker status.

Conclusion: Patients experiencing ongoing AKI during ADHF admission were at increased risk of death and other adverse cardiorenal outcomes. Differential uAGT response in patients receiving RAS blockers with ongoing AKI suggests biomarkers may be helpful in predicting treatment responses and cardiorenal outcomes.

References

Metra M, Teerlink J, Cotter G, Davison B, Felker G, Filippatos G . Effects of Serelaxin in Patients with Acute Heart Failure. N Engl J Med. 2019; 381(8):716-726. DOI: 10.1056/NEJMoa1801291. View

Damman K, Valente M, Voors A, OConnor C, Van Veldhuisen D, Hillege H . Renal impairment, worsening renal function, and outcome in patients with heart failure: an updated meta-analysis. Eur Heart J. 2013; 35(7):455-69. DOI: 10.1093/eurheartj/eht386. View

Massie B, OConnor C, Metra M, Ponikowski P, Teerlink J, Cotter G . Rolofylline, an adenosine A1-receptor antagonist, in acute heart failure. N Engl J Med. 2010; 363(15):1419-28. DOI: 10.1056/NEJMoa0912613. View

Berra G, Garin N, Stirnemann J, Jannot A, Martin P, Perrier A . Outcome in acute heart failure: prognostic value of acute kidney injury and worsening renal function. J Card Fail. 2015; 21(5):382-390. DOI: 10.1016/j.cardfail.2014.12.015. View

Sokolski M, Zymlinski R, Biegus J, Siwolowski P, Nawrocka-Millward S, Todd J . Urinary levels of novel kidney biomarkers and risk of true worsening renal function and mortality in patients with acute heart failure. Eur J Heart Fail. 2017; 19(6):760-767. DOI: 10.1002/ejhf.746. View

Breidthardt T, Socrates T, Drexler B, Noveanu M, Heinisch C, Arenja N . Plasma neutrophil gelatinase-associated lipocalin for the prediction of acute kidney injury in acute heart failure. Crit Care. 2012; 16(1):R2. PMC: 3396227. DOI: 10.1186/cc10600. View

Metra M, Davison B, Bettari L, Sun H, Edwards C, Lazzarini V . Is worsening renal function an ominous prognostic sign in patients with acute heart failure? The role of congestion and its interaction with renal function. Circ Heart Fail. 2011; 5(1):54-62. DOI: 10.1161/CIRCHEARTFAILURE.111.963413. View

Bart B, Goldsmith S, Lee K, Givertz M, OConnor C, Bull D . Ultrafiltration in decompensated heart failure with cardiorenal syndrome. N Engl J Med. 2012; 367(24):2296-304. PMC: 3690472. DOI: 10.1056/NEJMoa1210357. View

Angeletti S, Fogolari M, Morolla D, Capone F, Costantino S, Spoto S . Role of Neutrophil Gelatinase-Associated Lipocalin in the Diagnosis and Early Treatment of Acute Kidney Injury in a Case Series of Patients with Acute Decompensated Heart Failure: A Case Series. Cardiol Res Pract. 2016; 2016:3708210. PMC: 4789043. DOI: 10.1155/2016/3708210. View

10.

Boulos J, Darawsha W, Abassi Z, Azzam Z, Aronson D . Treatment patterns of patients with acute heart failure who develop acute kidney injury. ESC Heart Fail. 2018; 6(1):45-52. PMC: 6351897. DOI: 10.1002/ehf2.12364. View

11.

Palazzuoli A, Ruocco G, Pellegrini M, De Gori C, Del Castillo G, Franci B . Comparison of Neutrophil Gelatinase-Associated Lipocalin Versus B-Type Natriuretic Peptide and Cystatin C to Predict Early Acute Kidney Injury and Outcome in Patients With Acute Heart Failure. Am J Cardiol. 2015; 116(1):104-11. DOI: 10.1016/j.amjcard.2015.03.043. View

12.

Kobori H, Ozawa Y, Suzaki Y, Prieto-Carrasquero M, Nishiyama A, Shoji T . Young Scholars Award Lecture: Intratubular angiotensinogen in hypertension and kidney diseases. Am J Hypertens. 2006; 19(5):541-50. PMC: 2063567. DOI: 10.1016/j.amjhyper.2005.11.014. View

13.

Dankova M, Minarikova Z, Danko J, Gergel J, Pontuch P, Goncalvesova E . Novel biomarkers for prediction of acute kidney injury in acute heart failure. Bratisl Lek Listy. 2020; 121(5):321-324. DOI: 10.4149/BLL_2020_050. View

14.

Damman K, Valente M, Van Veldhuisen D, Cleland J, OConnor C, Metra M . Plasma Neutrophil Gelatinase-Associated Lipocalin and Predicting Clinically Relevant Worsening Renal Function in Acute Heart Failure. Int J Mol Sci. 2017; 18(7). PMC: 5535961. DOI: 10.3390/ijms18071470. View

15.

Murray P, Wettersten N, Van Veldhuisen D, Mueller C, Filippatos G, Nowak R . Utility of Urine Neutrophil Gelatinase-Associated Lipocalin for Worsening Renal Function during Hospitalization for Acute Heart Failure: Primary Findings of the Urine N-gal Acute Kidney Injury N-gal Evaluation of Symptomatic Heart Failure Study.... J Card Fail. 2019; 25(8):654-665. DOI: 10.1016/j.cardfail.2019.05.009. View

16.

Bhandari S, Mehta S, Khwaja A, Cleland J, Ives N, Brettell E . Renin-Angiotensin System Inhibition in Advanced Chronic Kidney Disease. N Engl J Med. 2022; 387(22):2021-2032. DOI: 10.1056/NEJMoa2210639. View

17.

Okubo Y, Sairaku A, Morishima N, Ogi H, Matsumoto T, Kinoshita H . Increased Urinary Liver-Type Fatty Acid-Binding Protein Level Predicts Worsening Renal Function in Patients With Acute Heart Failure. J Card Fail. 2018; 24(8):520-524. DOI: 10.1016/j.cardfail.2018.07.003. View

18.

Chen C, Yang X, Lei Y, Zha Y, Liu H, Ma C . Urinary Biomarkers at the Time of AKI Diagnosis as Predictors of Progression of AKI among Patients with Acute Cardiorenal Syndrome. Clin J Am Soc Nephrol. 2016; 11(9):1536-1544. PMC: 5012473. DOI: 10.2215/CJN.00910116. View

19.

Chen H, Anstrom K, Givertz M, Stevenson L, Semigran M, Goldsmith S . Low-dose dopamine or low-dose nesiritide in acute heart failure with renal dysfunction: the ROSE acute heart failure randomized trial. JAMA. 2013; 310(23):2533-43. PMC: 3934929. DOI: 10.1001/jama.2013.282190. View

20.

Atici A, Emet S, Cakmak R, Yuruyen G, Alibeyoglu A, Akarsu M . Type I cardiorenal syndrome in patients with acutely decompensated heart failure: the importance of new renal biomarkers. Eur Rev Med Pharmacol Sci. 2018; 22(11):3534-3543. DOI: 10.26355/eurrev_201806_15180. View