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Circ Heart Fail. 2019 Jun;12(6):e005552. doi: 10.1161/CIRCHEARTFAILURE.118.005552. Epub 2019 Jun 5.

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

Author information

1
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.
2
Cardiology Division, Lewis Katz School of Medicine at Temple University, Philadelphia, PA (M.A.B.-B.).
3
Division of Renal Medicine, Brigham and Women's Hospital, Boston. MA (J.V.B.).
4
Nephrology (F.P.W.), Yale University School of Medicine, New Haven, CT.
5
Division of Nephrology and Hypertension, Vanderbilt Center for Kidney Disease (VCKD) and Integrated Program for AKI (VIP-AKI), Department of Medicine, Vanderbilt University Medical Center, Nashville, TN (E.D.S.).
6
Duke University Medical Center and Duke Clinical Research Institute, Durham, NC (G.M.F., K.K.A.).
7
Division of Cardiology, Hennepin County Medical Center, Minneapolis, MN (B.A.B.).
8
Section of Heart Failure and Cardiac Transplantation, Cleveland Clinic, OH (W.H.W.T.).

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, Pinteraction=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.

KEYWORDS:

biomarkers; heart failure; incidence; kidney; ultrafiltration

PMID:
31163974
PMCID:
PMC6585463
[Available on 2020-06-05]
DOI:
10.1161/CIRCHEARTFAILURE.118.005552

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