Espinosa Begoña, Llauger Lluís, Gil Víctor, Escoda Rosa, Jacob Javier, Aguirre Alfons, Mojarro Enrique Martín, Tost Josep, Alquézar-Arbé Aitor, López-Grima María Luisa, Millán Javier, Massó Marta, Cuquerella Guillem Suñén, Pagán Francesc, Núñez Julio, Dauw Jeroen, Müllens Wilfried, Llorens Pere, Miró Òscar
Emergency Department, Short Stay Unit and Hospitalization at Home Unit, Hospital General de Alicante, Instituto de Investigación Sanitaria y Biomédica de Alicante (ISABIAL), Universidad Miguel Hernández, Alicante, Spain.
Emergency Department, Hospital Universitari de Vic, Barcelona, Catalonia, Spain.
Intern Emerg Med. 2025 Aug;20(5):1553-1564. doi: 10.1007/s11739-024-03796-0. Epub 2024 Oct 29.
To investigate if worsening renal function (WRF) appearing in some patients with acute heart failure (AHF) after intravenous furosemide initiation is influenced by severity of congestion. We conducted a retrospective secondary analysis of consecutive patients diagnosed with AHF and prospectively included in 10 Spanish emergency departments (EDs) for whom serum creatinine at ED arrival and after 2-7 days of intravenous furosemide initiation were available. Congestion was clinically evaluated by identification of 7 signs/symptoms and by chest X-ray. The outcome was WRF, defined as a delta-creatinine ≥ 0.3 mg/dL. Risk of WRF according to congestion was estimated in models adjusted by patient baseline characteristics and vitals at ED arrival, and interaction was also investigated. We included 3027 patients (median age 82 years, 56% women), and 657 (21.7%) presented WRF after intravenous furosemide initiation. When signs/symptoms were individually considered, only lower limbs edema was associated with decreased risk of WRF (20.1% vs. 24.8%; OR = 0.76, 95%CI = 0.64-0.91). After adjustment, lower limbs edema persisted inversely associated with WRF (aOR = 0.78, 95%CI = 0.65-0.94), with significant lower risk for patients ≤ 80 years and without chronic kidney disease, functional limitation, and hypoxemia (p for interaction 0.01, 0.04, 0.02 and 0.03, respectively). Neither degree of clinical congestion (number of signs/symptoms of congestion) nor radiological congestion in chest X-ray were related to WRF. Worsening renal function was associated with a higher 1-year all-cause mortality (40.1% vs 34.6%; HR = 1.27, 1.10-1.46; aHR = 1.331, 1.151-1.540). In patients with WRF, liver cirrhosis, chronic treatment with loop diuretics and renin-angiotensin system inhibitors, age (> 80 years), dementia, heart valve disease and NYHA class III-IV were associated with higher mortality. Intravenous furosemide initiation in patients with AHF without lower limbs edema must be cautious, as they are at increasing risk of developing WRF during the next following days, which in turn is associated with a higher 1-year mortality.
为研究急性心力衰竭（AHF）患者静脉注射呋塞米后出现的肾功能恶化（WRF）是否受充血严重程度影响。我们对连续诊断为AHF且前瞻性纳入10家西班牙急诊科的患者进行了回顾性二次分析，这些患者在急诊科就诊时及静脉注射呋塞米2 - 7天后的血清肌酐数据可用。通过识别7种体征/症状及胸部X线对充血进行临床评估。结局为WRF，定义为肌酐增量≥0.3mg/dL。在根据患者基线特征和急诊科就诊时的生命体征进行调整的模型中估计充血相关的WRF风险，并研究相互作用。我们纳入了3027例患者（中位年龄82岁，56%为女性），657例（21.7%）在静脉注射呋塞米后出现WRF。当单独考虑体征/症状时，仅下肢水肿与WRF风险降低相关（20.1%对24.8%；OR = 0.76，95%CI = 0.64 - 0.91）。调整后，下肢水肿与WRF仍呈负相关（校正OR = 0.78，95%CI = 0.65 - 0.94），对于年龄≤80岁且无慢性肾脏病、功能受限和低氧血症的患者风险显著降低（相互作用的P值分别为0.01、0.04、0.02和0.03）。临床充血程度（充血体征/症状数量）及胸部X线的影像学充血均与WRF无关。肾功能恶化与1年全因死亡率较高相关（40.1%对34.6%；HR = 1.27，1.10 - 1.46；校正HR = 1.331，1.151 - 1.540）。在出现WRF的患者中，肝硬化、长期使用袢利尿剂和肾素 - 血管紧张素系统抑制剂治疗、年龄（>80岁）、痴呆、心脏瓣膜病和纽约心脏协会（NYHA）心功能分级III - IV级与较高死亡率相关。对于无下肢水肿的AHF患者，静脉注射呋塞米时必须谨慎，因为他们在接下来几天发生WRF的风险增加，而这又与1年较高死亡率相关。
