Renal Effects of Intensive Volume Removal in Heart Failure Patients With Preexisting Worsening Renal Function.

Pubmed ID: 31163974

Pubmed Central ID: PMC6585463

Journal: Circulation. Heart failure

Publication Date: June 1, 2019

Affiliation: Sections of Cardiovascular Medicine (V.S.R., T.A., D.D.M., E.J.V., J.M.T.), Yale University School of Medicine, New Haven, CT.

MeSH Terms: Humans, Male, Female, Aged, Aged, 80 and over, Middle Aged, Heart Failure, Prospective Studies, Creatinine, Kidney, Biomarkers, Lipocalin-2

Grants: K23 HL114868, L30 HL115790, K23 HL128933, K23 DK097201, R01 HL128973, P30 DK079310, UL1 TR001863, R01 DK072381, R01 DK113191, R01 HL139629, R37 DK039773, R01 DK039773

Authors: Testani JM, Siew ED, Bart BA, Felker GM, Wilson FP, Ahmad T, Tang WHW, Rao VS, Brisco-Bacik MA, Bonventre JV, Anstrom KK, Mahoney DD, Velazquez EJ

Cite As: Rao VS, Ahmad T, Brisco-Bacik MA, Bonventre JV, Wilson FP, Siew ED, Felker GM, Anstrom KK, Mahoney DD, Bart BA, Tang WHW, Velazquez EJ, Testani JM. Renal Effects of Intensive Volume Removal in Heart Failure Patients With Preexisting Worsening Renal Function. Circ Heart Fail 2019 Jun;12(6):e005552. Epub 2019 Jun 5.

Studies:

Abstract

Background The relationship between intensive volume removal in acute decompensated heart failure patients with preexisting worsening renal function (WRF) and renal tubular injury, postdischarge renal function, and clinical outcomes is unknown. Methods and Results We used data from the multicenter CARRESS-HF trial (Cardiorenal Rescue Study in Acute Decompensated Heart Failure) that randomized patients with acute decompensated heart failure and preexisting WRF to intensive volume removal with stepped pharmacological therapy or fixed rate ultrafiltration. Patients in the urinary renal tubular injury biomarker substudy (NAG [N-acetyl-b-D-glucosaminidase], KIM-1 [kidney injury molecule-1], and NGAL [neutrophil gelatinase-associated lipocalin]) were evaluated (N=105). The severity of prerandomization WRF was unrelated to baseline renal tubular injury biomarkers ( r=0.14; P=0.17). During randomized intensive volume removal, creatinine further worsened in 53% of patients. Despite a small to moderate magnitude increase in creatinine in most of these patients, postrandomization WRF was strongly associated with worsening in renal tubular injury biomarkers (odds ratio, 12.6; P=0.004). This observation did not differ by mode of volume removal (stepped pharmacological therapy versus ultrafiltration, P<sub>interaction</sub>=0.46). Increase in renal tubular injury biomarkers was associated with a higher incidence of hemoconcentration (odds ratio, 3.1; P=0.015), and paradoxically, better recovery of creatinine at 60 days ( P=0.01). Conclusions In acute decompensated heart failure patients with preexisting WRF, intensive volume removal resulted in a further worsening of creatinine approximately half of the time, a finding associated with a rise in tubular injury biomarkers. However, decongestion and renal function recovery at 60 days were superior in patients with increased tubular injury markers. These data suggest that the benefits of decongestion may outweigh any modest or transient increases in serum creatinine or tubular injury markers that occur during intensive volume removal. Clinical Trial Registration URL: https://www.clinicaltrials.gov . Unique identifier: NCT00608491.