Clinical Investigation
Worsening Renal Function and Prognosis in Heart Failure: Systematic Review and Meta-Analysis

https://doi.org/10.1016/j.cardfail.2007.04.008Get rights and content

Abstract

Background

Renal impairment is associated with increased mortality in heart failure (HF). Recently, reports suggest that worsening renal function (WRF) is another predictor of clinical outcome in HF. The present study was designed to establish the proportion of patients with HF that exhibits (WRF) and the associated risk for mortality and hospitalization by conducting a systematic review and meta-analysis.

Methods and Results

A systematic search of MEDLINE revealed 8 studies on the relationship between WRF and mortality in 18,634 patients with HF. The mortality risk associated with WRF was estimated using random-effects meta-analysis. WRF was defined as an increase in serum creatinine ≥0.2 mg/dL or a corresponding decrease in estimated glomerular filtration rate ≥5 mL·min·1.73 m2. Subgroup analysis included differentiation between in- and out-hospital patients, degree of WRF and time until end point occurrence. WRF developed in 4,734 (25%) patients and was associated with a higher risk for mortality (odds ratio [OR] = 1.62; 95% confidence interval [CI] 1.45–1.82, P < .001) and hospitalization (OR = 1.30, 95% CI 1.04–1.62, P = .022). The severity of WRF was also associated with greater mortality. Patients with impaired renal function at baseline were more prone to progressive renal function loss.

Conclusions

WRF predicts substantially higher rates of mortality and hospitalization in patients with HF.

Section snippets

Literature Search

MEDLINE was searched to identify eligible studies using search tools provided by PubMed (http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.shtml; accessed January 2007). These search tools have been validated by Haynes et al as optimizing retrieval.6 We also used keywords including (worsening) renal (kidney) function, WRF, heart failure, mortality, prognosis, left ventricular dysfunction, creatinine, and a combination of these. We included articles limited to the English language.

Study Search and General Characteristics

Of 1124 citations retrieved by the search, 13 investigated the relationship between WRF and outcome. Five studies were excluded for reasons shown in Fig. 1.11, 12, 13, 14, 15 Eight studies remained for our analysis.7, 8, 16, 17, 18, 19, 20, 21 Of all selected studies, 3 assessed deteriorating renal function in outpatients,7, 18, 20 whereas the remaining 5 investigated patients in the in-hospital setting8, 16, 17, 19, 21 with follow-up extending beyond admission. One study described the

Discussion

To our knowledge, this is the first systematic review to address the relation between WRF and outcome in patients with HF. WRF was common, whether defined by increase in serum creatinine or eGFR, especially in patients with impaired renal function at baseline. It was associated with an increase in mortality and all-cause hospitalization especially when WRF was more severe. This was true whether WRF occurred in the setting of acute or chronic HF. On the other hand, improvement in renal function,

Conclusion

Worsening of renal function is commonly observed in patients with HF, especially in those who already have renal dysfunction. WRF is associated with an increase in all-cause mortality, especially in patients with more severe WRF, and all cause. On the other hand, improvement of kidney function is associated with better survival. Therefore therapy targeted at improving kidney function in HF may be a valuable new strategy to improve prognosis in this high-mortality patient group. Further research

Acknowledgment

The authors thank Dr. N. Kahn and Dr. I. Ma of the University of British Columbia, Vancouver, British Columbia, and Dr. A.S. Rigby, Dr. K. Goode, and Dr. R. de Silva of the Castle Hill Hospital, University of Hull, Cottingham, United Kingdom, for providing us with crude mortality data that was not available in their original reports.

References (34)

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Kevin Damman is supported by The Netherlands Heart Foundation (grant 2006B157).

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