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Kidney Week

Abstract: PO0270

Rates of In-Hospital Decongestion and Association with Cardiovascular Outcomes Among Patients Admitted for Acute Heart Failure

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials

Authors

  • McCallum, Wendy I., Tufts Medical Center, Boston, Massachusetts, United States
  • Tighiouart, Hocine, Tufts Medical Center, Boston, Massachusetts, United States
  • Testani, Jeffrey M., Yale University School of Medicine, New Haven, Connecticut, United States
  • Griffin, Matthew, Yale University School of Medicine, New Haven, Connecticut, United States
  • Konstam, Marvin, Tufts Medical Center, Boston, Massachusetts, United States
  • Udelson, James, Tufts Medical Center, Boston, Massachusetts, United States
  • Sarnak, Mark J., Tufts Medical Center, Boston, Massachusetts, United States
Background

Decongestion is an important goal in the management of acute heart failure (HF) among patients with heart failure with reduced ejection fraction (HFrEF), but whether the rate of decongestion is associated with cardiovascular (CVD) outcomes is unknown.

Methods

Using data from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial, we used multivariable Cox regression models to evaluate the association between the rate of in-hospital change in assessments of volume overload, including b-type natriuretic peptide (BNP), N-terminal prob-type natriuretic peptide (NT-proBNP) and clinical congestion score (0-12), as well as change in hemoconcentration including measures of hematocrit, albumin and total protein with risk of the trial’s primary endpoint of a composite outcome of CVD mortality or HF hospitalization.

Results

Among 3500 patients with median 10 month follow-up, 1369 (39%) experienced the composite outcome of CVD mortality or HF hospitalization. There were no differences in baseline kidney function between those in the quartile of most rapid decongestion compared to least rapid (mean eGFR 59±23 vs 57±23 ml/min/1.73m2, respectively). Overall, despite in-hospital eGFR decline with decongestion (-0.2 ml/min/1.73m2 per day), faster decongestion was associated with decreased risk of both CVD mortality and HF hospitalization (Table).

Conclusion

Among patients with HFrEF admitted for HF, achievement of faster rates of decongestion is associated with reduced risk of CVD mortality and HF hospitalization. Whether this suggests that either more rapid decongestion provides cardiovascular benefit, or whether the ability to rapidly decongest is a proxy for a healthier individual, remains to be further evaluated.

  Quartile 1. Least rapid decongestionQuartile 2Quartile 3Quartile 4. Most rapid decongestion
Volume OverloadBNP1.00 (1.00, 1.00)0.69 (0.57, 0.83)0.62 (0.51, 0.75)0.46 (0.37, 0.58)
NT-proBNP1.00 (1.00, 1.00)0.98 (0.79, 1.21)0.78 (0.62, 0.98)0.52 (0.40, 0.68)
Congestion Score1.00 (1.00, 1.00)0.92 (0.79, 1.08)0.88 (0.75, 1.04)0.91 (0.77, 1.09)
HemoconcentrationHematocrit1.00 (1.00, 1.00)0.90 (0.77, 1.06)0.82 (0.70, 0.97)0.71 (0.60, 0.84)
Albumin1.00 (1.00, 1.00)0.96 (0.83, 1.13)0.82 (0.70, 0.97)0.75 (0.63, 0.88)
Total Protein1.00 (1.00, 1.00)0.90 (0.77, 1.05)0.88 (0.74, 1.03)0.71 (0.59, 0.84)
*Adjusted for: age, sex, race, randomization group (tolvaptan vs placebo), body mass index, medication use (angiotensin converting enzyme inhibitor or angiotensin II receptor blocker, mineralocorticoid receptor antagonist), ejection fraction, New York Heart Association functional class, systolic blood pressure, eGFR at discharge and respective baseline biomarker level
Abbreviations: BNP, b-type natriuretic peptide; NT-proBNP: N-terminal pro b-type natriuretic peptide; HF, heart failure