title: Is worsening renal function an ominous prognostic sign in patients with acute heart failure? The role of congestion and its interaction with renal function.
abstract: BACKGROUND
  Worsening renal function (WRF), traditionally defined as an increase in serum creatinine levels ≥0.3 mg/dL, is a frequent finding in patients with acute heart failure (AHF) and has been associated with poorer outcomes in some but not all studies. We hypothesized that these discrepancies may be caused by the interaction between WRF and congestion in AHF patients.
  
  
  RESULTS
  We measured serum creatinine levels on a daily basis during the hospitalization and assessed the persistence of signs of congestion at discharge in 599 consecutive patients admitted at our institute for AHF. They had a postdischarge mortality and mortality or AHF readmission rates of 13% and 43%, respectively, after 1 year. Patients were subdivided into 4 groups according to the development or not of WRF and the persistence of ≥1 sign of congestion at discharge. Patients with WRF and no congestion had similar outcomes compared with those with no WRF and no congestion, whereas the risk of death or of death or AHF readmission was increased in the patients with persistent congestion alone and in those with both WRF and congestion (hazard ratio, 5.35; 95% confidence interval, 3.0-9.55 at univariable analysis; hazard ratio, 2.44; 95% confidence interval, 1.24-4.18 at multivariable analysis for mortality; hazard ratio, 2.14; 95% confidence interval, 1.39-3.3 at univariable analysis; and hazard ratio, 1.39; 95% confidence interval, 0.88-2.2 at multivariable analysis for mortality and rehospitalizations).
  
  
  CONCLUSIONS
  WRF alone, when detected using serial serum creatinine measurements, is not an independent determinant of outcomes in patients with AHF. It has an additive prognostic value when it occurs in patients with persistent signs of congestion.
authors.affiliation: Institute of Cardiology, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy. metramarco@libero.it
authors.forename: Marco
authors.initials: M
authors.lastname: Metra
authors.forename: Beth
authors.initials: B
authors.lastname: Davison
authors.forename: Luca
authors.initials: L
authors.lastname: Bettari
authors.forename: Hengrui
authors.initials: H
authors.lastname: Sun
authors.forename: Christopher
authors.initials: C
authors.lastname: Edwards
authors.forename: Valentina
authors.initials: V
authors.lastname: Lazzarini
authors.forename: Barbara
authors.initials: B
authors.lastname: Piovanelli
authors.forename: Valentina
authors.initials: V
authors.lastname: Carubelli
authors.forename: Silvia
authors.initials: S
authors.lastname: Bugatti
authors.forename: Carlo
authors.initials: C
authors.lastname: Lombardi
authors.forename: Gad
authors.initials: G
authors.lastname: Cotter
authors.forename: Livio
authors.initials: L
authors.lastname: Dei Cas
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D015415:Biomarkers / Q000097:blood; D003404:Creatinine / Q000097:blood; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000097:blood* / Q000175:diagnosis* / Q000401:mortality / Q000503:physiopathology*; D006801:Humans; D007668:Kidney / Q000503:physiopathology*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011379:Prognosis; D012189:Retrospective Studies; D015996:Survival Rate
chemical_list: D015415:Biomarkers; D003404:Creatinine