The Renal Effects of Aggressive Volume Removal in Heart Failure Patients with Preexisting Worsening Renal Function

摘要

IntroductionAccumulating data suggests that worsening renal function (WRF) during decongestion of acute decompensated heart failure (ADHF) patients is a benign and transient finding. However, it is unknown if continued aggressive volume removal in patients with preexisting WRF is harmful. HypothesisAggressive volume removal in ADHF patients with preexisting WRF will be associated with renal tubular injury. MethodsWe used data from the multicenter CARRESS-HF trial that randomized patients with ADHF and pre-existing WRF to aggressive volume removal with stepped pharmacologic therapy (SPT) versus fixed rate ultrafiltration (UF). Patients in the urinary renal tubular injury biomarker (NAG, KIM-1, and NGAL) sub-study were evaluated (N=105). ResultsThe severity of pre-randomization increase in creatinine was unrelated to baseline levels of renal tubular injury biomarkers (r=0.1,P=0.31). During randomized aggressive volume removal, creatinine further worsened in 53% of patients. Those with post-randomization WRF were highly likely to have a concurrent increase in renal tubular injury biomarkers (OR=12.6,P=0.004). This finding did not differ by mode of volume removal (SPT vs. UF,Pinteraction=0.47). Increase in renal tubular injury biomarkers during decongestion was associated with a higher incidence of hemoconcentration (OR=3.1,P=0.015), and paradoxically, better recovery of creatinine at 60 days (P=0.01). Post-randomization WRF (P=0.63) and worsening tubular injury biomarkers (P=0.91) were not associated with death or rehospitalization at 60 days. ConclusionsAggressive volume removal in the setting of ADHF with preexisting WRF was associated with continued increase of creatinine in approximately half of patients. Worsened creatinine in this setting was accompanied by evidence of renal tubular injury. However, decongestion and renal function recovery at 60 days was superior in patients with worsening tubular injury markers. This suggests that increases in creatinine with effective decongestion may be clinically benign and transient, even when accompanied by renal tubular injury.