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Heart Failure in Adults With Chronic Kidney Disease
Study Questions:
What are the rates of heart failure (HF) hospitalizations and re-hospitalizations within a large chronic kidney disease (CKD) population, and what is the association between the burden of HF hospitalizations with the risk of subsequent CKD progression and all-cause mortality?
Methods:
The study authors measured the estimated glomerular filtration rate (eGFR) and urine albumin-to-creatinine ratio (ACR) at baseline in 3,939 individuals with mild to severe CKD enrolled in the prospective CRIC (Chronic Renal Insufficiency Cohort) study. They calculated crude rates and rate ratios of HF hospitalizations and 30-day HF re-hospitalizations using Poisson regression models. They utilized Cox regression to assess the association of the frequency of HF hospitalizations within the first 2 years of follow-up with risk of subsequent CKD progression and mortality.
Results:
The final cohort was comprised of 3,791 participants after excluding patients with missing data. A total of 1,774 HF hospitalizations during follow-up were observed among 3,791 participants (range 0-17 per participant per year), of which 702 episodes were incident HF and 1,072 were among participants with known HF. Median follow-up for participants who experienced ≥1 HF hospitalization was 7.8 years (interquartile range, 5.6-9.2 years).
The investigators reported that the crude rate of HF admissions was 5.8 per 100 person-years (95% confidence interval [CI], 5.2-6.4; with higher rates of HF with preserved ejection fraction vs. HF with reduced ejection fraction). They found that the rate of HF was 2.1- and 2.9-fold higher for participants with eGFRs of 30-44 and <30 ml/min/1.73 m2, respectively (vs. eGFR >45 ml/min/1.73 m2); the rate ratios were 1.7 and 2.2 for eGFR 30-44 and <30 ml/min/1.73 m2 (vs. >45 ml/min/1.73 m2), respectively. They also reported that adjusted rates of HF hospitalization were significantly higher in those with higher urine ACR (vs. urine ACR <30 mg/g); the rate ratios were 1.9 and 2.6 for urine ACR 30-299 and ≥300 mg/g, respectively.
Overall, 20.6% of participants had a subsequent HF re-admission within 30 days. HF hospitalization within 2 years of study entry was associated with greater adjusted risks for CKD progression (1 hospitalization: hazard ratio [HR], 1.93; 95% CI, 1.40-2.67; 2 hospitalizations: HR, 2.14; 95% CI, 1.30-3.54) and all-cause mortality (1 hospitalization: HR, 2.20; 95% CI, 1.71-2.84; 2 hospitalizations: HR, 3.06; 95% CI, 2.23-4.18).
Conclusions:
The authors concluded that the rates of HF hospitalizations and re-hospitalization were high, with even higher rates across categories of lower eGFR and higher urine ACR. They also concluded that patients with CKD hospitalized with HF had greater risks of CKD progression and death.
Perspective:
This is an important study because it confirms what most HF specialists know, that is, acute decompensated HF is frequently due to cardiorenal dysfunction or accompanied by azotemia. Conducting clinical trials evaluating best therapies in cardiorenal dysfunction is the next step to improve survival.
Clinical Topics: Diabetes and Cardiometabolic Disease, Geriatric Cardiology, Heart Failure and Cardiomyopathies, Prevention, Acute Heart Failure
Keywords: Albumins, Azotemia, Creatinine, Disease Progression, Geriatrics, Glomerular Filtration Rate, Heart Failure, Hospitalization, Kidney Diseases, Metabolic Syndrome, Primary Prevention, Renal Insufficiency, Chronic
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