Department of Cardiology, Osaka Medical and Pharmaceutical University, Osaka, Japan.
Department of Cardiology, Hokusetsu General Hospital, Osaka, Japan.
ESC Heart Fail. 2023 Jun;10(3):1726-1734. doi: 10.1002/ehf2.14326. Epub 2023 Feb 25.
Worsening renal function (WRF) often develops during heart failure (HF) treatment. However, prognostic implications of WRF in acute HF remain controversial, and risk stratification of WRF is challenging. Although the fibrosis-4 index (FIB-4) was initially established as a liver fibrosis marker, recent studies show that high FIB-4 is associated with venous congestion and poor prognosis in acute HF. This study aimed to evaluate whether FIB-4 could identify prognostically relevant and non-relevant WRF in patients with acute HF.
We retrospectively analysed data from a single-centre registry on acute HF at our university hospital between January 2015 and June 2021. This study included patients with acute HF aged ≥20 years who were immediately hospitalized and had brain natriuretic peptide levels ≥100 pg/mL at admission. WRF was defined as increases of ≥0.3 mg/dL and >25% in serum creatinine level from admission to discharge. FIB-4 scores were calculated before discharge. The primary endpoint was all-cause mortality within 1 year of discharge. Based on the presence of WRF and whether FIB-4 scores were above the median, patients were stratified into four groups: no WRF and lower FIB-4 scores, no WRF and higher FIB-4 scores, WRF and lower FIB-4 scores, and WRF and higher FIB-4 scores. The patients were followed up via clinical visits or telephone interviews. Clinical outcomes were collected from the electronic medical records.
Of the 969 patients hospitalized for acute HF (76 ± 11 years, 59% men), 118 patients (12%) had WRF at discharge. The median (interquartile range) FIB-4 score at discharge was 2.36 (1.55-3.25). The primary endpoint occurred in 136 patients (14.0%). The 1 year mortality rates were 10.5% in the no WRF and lower FIB-4 scores (≤2.36) group (n = 428), 16.1% in the no WRF and higher FIB-4 scores (>2.36) group (n = 423), 12.5% in the WRF and lower FIB-4 scores group (n = 56), and 25.8% in the WRF and higher FIB-4 scores group (n = 62) (P = 0.005). Kaplan-Meier analysis demonstrated higher all-cause mortality in the WRF and higher FIB-4 group (log-rank P = 0.003). In the Cox regression analysis, only the WRF and higher FIB-4 scores group was associated with an increased risk of mortality compared with the no WRF and lower FIB-4 scores group (hazard ratio = 2.11, 95% confidence interval: 1.07-4.18, P = 0.032), despite adjusting for other confounding factors.
FIB-4 is a valuable risk stratification marker for WRF in patients with acute HF. The underlying mechanism and potential clinical importance of these observations require further investigation.
在心力衰竭（HF）治疗过程中，肾功能恶化（WRF）常逐渐出现。然而，WRF 在急性 HF 中的预后意义仍存在争议，WRF 的风险分层具有挑战性。虽然纤维化-4 指数（FIB-4）最初被确立为肝纤维化标志物，但最近的研究表明，高 FIB-4 与急性 HF 中的静脉充血和不良预后相关。本研究旨在评估 FIB-4 是否可识别急性 HF 患者中有预后意义和无预后意义的 WRF。
我们回顾性分析了 2015 年 1 月至 2021 年 6 月在我们大学医院因急性 HF 住院的单中心登记处的数据。该研究纳入了年龄≥20 岁的急性 HF 患者，这些患者立即住院且入院时脑钠肽水平≥100pg/mL。WRF 定义为从入院到出院时血清肌酐水平升高≥0.3mg/dL 和>25%。在出院前计算 FIB-4 评分。主要终点为出院后 1 年内的全因死亡率。根据 WRF 的存在和 FIB-4 评分是否高于中位数，将患者分为四组：无 WRF 且 FIB-4 评分较低、无 WRF 且 FIB-4 评分较高、WRF 且 FIB-4 评分较低和 WRF 且 FIB-4 评分较高。通过临床访视或电话访谈对患者进行随访。通过电子病历收集临床结局。
在因急性 HF 住院的 969 例患者中（76±11 岁，59%为男性），118 例（12%）在出院时出现 WRF。出院时的中位数（四分位距）FIB-4 评分为 2.36（1.55-3.25）。主要终点在 136 例患者（14.0%）中发生。无 WRF 且 FIB-4 评分较低（≤2.36）组（n=428）、无 WRF 且 FIB-4 评分较高（>2.36）组（n=423）、WRF 且 FIB-4 评分较低组（n=56）和 WRF 且 FIB-4 评分较高组（n=62）的 1 年死亡率分别为 10.5%、16.1%、12.5%和 25.8%（P=0.005）。Kaplan-Meier 分析显示，WRF 且 FIB-4 评分较高组的全因死亡率较高（对数秩 P=0.003）。在 Cox 回归分析中，与无 WRF 且 FIB-4 评分较低组相比，仅 WRF 且 FIB-4 评分较高组与死亡率升高相关（风险比=2.11，95%置信区间：1.07-4.18，P=0.032），尽管对其他混杂因素进行了调整。
FIB-4 是急性 HF 患者 WRF 的有价值的风险分层标志物。这些观察结果的潜在机制和临床重要性需要进一步研究。
