Division of Nephrology, Tufts Medical Center, Boston, Massachusetts.
Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Tufts Clinical and Translational Science Institute, Tufts University, Boston, Massachusetts.
JACC Heart Fail. 2020 Jul;8(7):537-547. doi: 10.1016/j.jchf.2020.03.009. Epub 2020 Jun 10.
This study aimed to examine whether incorporation of a comprehensive set of measures of decongestion modifies the association of acute declines in kidney function with outcomes.
In-hospital acute declines in kidney function occur in approximately 20% to 30% of patients admitted with acute decompensated heart failure (ADHF) and may be associated with adverse outcomes.
Using data from EVEREST (Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan), we used multivariable Cox regression models to evaluate the association between in-hospital changes in estimated glomerular filtration rate (eGFR) with death and a composite outcome of cardiovascular death and hospitalization for heart failure. We evaluated eGFR declines within the context of changes in markers of volume overload including b-type natriuretic peptide (BNP), N-terminal prohormone of B-type natriuretic peptide (NT-proBNP), and weight, as well as changes in measures of hemoconcentration including hematocrit, albumin, and total protein.
Among 3,715 patients over a median follow-up of 9.9 months, every 30% decline in eGFR was associated with higher risk of both death (hazard ratio [HR]: 1.19; 95% confidence interval [CI]: 1.07 to 1.31) and the composite outcome (HR: 1.09; 95% CI: 1.01 to 1.18) in adjusted models. The acute decline in eGFR was no longer associated with higher risk of either outcome as long as there was evidence of decongestion, either by declines in BNP, NT-proBNP, or weight or by increases in hematocrit, albumin or total protein. Interaction testing between decline in eGFR and changes in hematocrit, albumin, and total protein was statistically significant (p interaction of <0.01 for death and p interaction of ≤0.01 for composite for all 3 biomarkers). Interaction between change in eGFR and changes in BNP (p interaction = 0.07 for death; p interaction = 0.08 for composite), NT-proBNP (p interaction = 0.15 for death; p interaction = 0.18 for composite) and weight (p interaction = 0.13 for death; p interaction = 0.19 for composite) did not meet statistical significance.
Overall, acute declines in eGFR are associated with adverse outcomes, with evidence of modification by changes in markers of decongestion, suggesting that they are no longer associated with adverse outcomes if these markers are concomitantly improving.
本研究旨在探讨在纳入一系列综合的去充血措施后，急性肾功能下降与结局的相关性是否发生改变。
约 20%至 30%的急性失代偿性心力衰竭（ADHF）患者在住院期间会出现急性肾功能下降，并且可能与不良结局相关。
利用 EVEREST（血管加压素拮抗剂治疗心力衰竭伴托伐普坦的疗效研究）的数据，我们使用多变量 Cox 回归模型评估住院期间估算肾小球滤过率（eGFR）的变化与死亡和心血管死亡和心力衰竭再住院的复合结局之间的相关性。我们评估了 eGFR 下降与容量超负荷标志物（包括 B 型利钠肽（BNP）、B 型利钠肽前体（NT-proBNP）和体重）以及血液浓缩标志物（包括红细胞压积、白蛋白和总蛋白）变化之间的关系。
在中位随访 9.9 个月的 3715 例患者中，eGFR 下降 30%与死亡（风险比[HR]：1.19；95%置信区间[CI]：1.07 至 1.31）和复合结局（HR：1.09；95%CI：1.01 至 1.18）的风险增加相关，在调整后的模型中。只要有去充血的证据，无论是 BNP、NT-proBNP 或体重下降，还是红细胞压积、白蛋白或总蛋白升高，急性 eGFR 下降与任何结局的高风险均不再相关。eGFR 下降与红细胞压积、白蛋白和总蛋白变化之间的交互检验具有统计学意义（p 交互<0.01，死亡；p 交互≤0.01，复合，所有 3 种生物标志物）。eGFR 变化与 BNP（死亡的 p 交互=0.07；复合的 p 交互=0.08）、NT-proBNP（死亡的 p 交互=0.15；复合的 p 交互=0.18）和体重（死亡的 p 交互=0.13；复合的 p 交互=0.19）变化之间的交互检验没有达到统计学意义。
总体而言，急性 eGFR 下降与不良结局相关，而去充血标志物的变化可改变这种相关性，这表明如果这些标志物同时改善，它们与不良结局之间不再相关。
