Acute Renal Injury In Patients With Acute Heart Failure: Risk Factors, And Prognosis

BackgroundAcute Decompensate Heart Failure(ADHF) occurs with high mobidity and mortility as well as its rehospitalization rate. The mobidity is about 0.4%to 2.0%. The aged People suffering from ADHF are more likely to die.Mortality in hospital 4%to7 %. Renal insufficiency usually happened in ADHF, It is called Cardiorenal Syndrome (CRS). Renal injury (RI) has a high incidence in these patients, It make the procedure managing ADHF complicated. Many clinical trials and registration researchs show there are much investigation need to do.Then these materials are restrained by its indirectation and insufficiency. Few literature afford information about underlying diseases in renal and the coherent clinical character in ADHF patients with RI. since there is no specific and effective management for the syndrome and blood purification do not improve patients’ outcome.It is well known that prevention is better than cure for RI. To promote clinical practice and further obtain the best outcomes for patients, it is important for clinicians to understand predictors of development and prognosis of RI. Thus, the study was performed retrospectively in patients with ADHF to investigate the risk predictors for the development and outcome of RI. The findings could assist in implementing strategies to prevent and prove outcome, which, in turn, could offer a survival benefit for patients suffered ADHF.Patients and Methods1. Study populationA retrospective clinical study was performed. The NangFang Hospital and is an academic medical centers affiliated with Sourthern Medical University. All patients with ADHF admitted to the CCU between January 2003 and December 2008 were screened. using the computerized hospital admissions and discharges database. Following patients were excluded from the study cohort:younger than 18 year old,staying in hospital less than 24 hrs, no serum creatinine (Scr) value nor urine output record in first 24 hour in the unit. If a patient had more than one admission during the study period, only the first admission was included in the study. As a result, 826 records were analysed in the study.2. DefinitionsRenal function injury was diagnosed according to (Modification of Diet in Renal Disease MDRD) eGFR<60ml/min/1.73m2, and RIFLE criteria is used to define (Acurt Kidney Injury).The RIFLE stratum (class R, class I or class F), which was based on the highest Scr level or the least urine output during CCU stay, was assigned to each patient for analysis. The clinical outcome of those with RI included patient outcome and renal outcome. Complete renal recovery is defined by a convalescent Scr not more than baseline.or eGFR>60ml/min/1.73m2.Partial renal recovery is said to occur if the above condition for complete recovery is not met but the patient does not require chronic dialysis.ADHF diagnosed according to European Society of Cardiology Guidelines on the Diagnosis and treatment of acute heart failure,New York Heart Association classification is used. 3. Data collectionThe patients’information, including demographic data, clinical data and laboratory data were collected from the database. All data were inputted using Epidata 3.0 software by a non-investigator data manager and repeated again, then double data were carried on consistency verification. All identifying information of patients was stripped of to preserve their anonymity.4. Statistical analysisIn statistical data, continuous variables were presented as mean±standard deviation (SD) or median (range) and categorical variables were presented as percentages. All variables were tested for normal distribution using the Kolmogorov-Smirnov test. One-way analysis of variance (one-way ANOVA) test or the Kruskal-Wallis H test for continuous variables according to their distribution; Fisher’s exact test or the chi-square test were applied to assess categorical data associated with RIFLE classifications (including no AKI, class R max, class I max and class F max). To elucidate the impact of each category of RIFLE criterion on hospital mortality and find the risk factors for development of AKI, multiple-variable logistic regression analyses was conducted, variables at p<0.05 in the univariate analysis and those considered clinically important were entered a multiple-variable logistic regression model. The Hosmer-Lemeshow test was employed to determine the goodness-of-fit of the model, P>0.05 was regarded as an acceptable model. The results of multivariate logistic regression analysis were summarized by estimating odds ratios (OR) and respective 95%confidence interval (CI). We considered double-sided P<0.05 as statistically significant. Data were analyzed using the SPSS version 13.0. Results1. Characteristic of patients with ADHFDuring the study period,826 patients admitted for ADHF were evaluated.61.3% is male, mean age was 61.2±14.5yrs (20-99years).562 patients(68.0%) have baseline eGFR≥60ml/min/1.73m2, Hypertension 341(41.3%),Scr 119.05±39.0 umol/l, Na+134.7±8.1mmol/l, Hb 124.6±14.2 g/dl, Urine protein 243(29.4%). 2. Character of AKI and ACRF126(22.4%) patients developed AKI, in the baseline eGFR≥60ml/min/m 1.73m2 group of 562 patients. and 86 patients(32.6%) developed ACRF in the baseline eGFR≥60ml/min/1.73m2 of 264 patients.the difference was statistically significant between and eGFR<60ml/min/1.73m2group.3. Outcome of AKI and ACRFPatients with the baseline eGFR≥60ml/min/m1.73m2 developed acute renal injury. The mortality of AKI-Risk, AKI-Injury, AKI-Failure patients were 20.4%, 24.5%,25.0%, seperately, among the alive patients when discharge, renal recovery completely in55.7%(54/97), Heart function recovery completely in76.3%(74/97)。55%(33/60) of ACRF patients recovery completely in renal function, heart function recovery completely in 46.7%(28/60).4. Risk factors for developing AKI and ACRF in patients with AHF4.1 Risk factors for developing AKIBaseline renal function eGFR≥60ml/min/1.73m2 developed acute renal injury,the risk factors including age,diabetic mellitus,other organ function injury, low sodium, large dose frusemide., large dose frusemide. Baseline renal function injury patients developed acute renal injury, the risk factors including higher than NYHA class 3, large dose frusemide,using digitaloid drugs, other vasodilating agents.Logistic regress were used.model fitting were good. 4.2 Risk factors for developing ACRFBaseline renal function eGFR<60ml/min/1.73m2 developed ACRF,the risk factors including other organ function injury, large dose frusemide. using digitaloid drugs, higher than NYHA class 3, and higher haemoglobin, using aldosterio were protect factors.5.Outcome affected by AKI or ACRF with AHF5.1 Risk predictors of mortality for AKI and ACRF patients with AHFBaseline renal function injury had a higher mortality than those with normal baseline renal function(14.8%vs 7.3%,P<0.05).AKI baseline eGFR≥60ml/min/1.73m2 had hiher motality than those had not AKI(5.9%vs 70.9%,P<0.05).Those developed acute renal injury in both group had higher motality and longer length of stay in CCU in serious renal injury groups.Risk factors for AKI death including acute renal injury,the higher rank of injury was,the danger of mortality it was.age, higher NYHA class than 3, other organ function insufficient(OR=1.125,95%CI:1.013-2.028), P=0.041), large dose frusemide(OR=1.012,95%CI:1.001-7.232, P=0.015), assisted ventilation(OR= 1.174,95%CI:1.012-4.332, P=0.001);cardiopulmonary resuscitation(OR=3.342, 95%CI:2.213-8.122, P=0.002), test of goodness of fit Hosmer-Lemeshowχ2=4.447, df=8, P=0.815,fitting is good.ACRF had a higher mortality than AKI.Logistic regression analysis found that ACRF mortality risk factor, hazard for death increasd as degree of injury aggravated. NYHA class higher than class 3. large dose frusemide, using digitaloid drugs cardiopulmonary resuscitation, other organ function insufficient5.2 Outcomes of NYHA classification in all AHF patientsPatients in AKI with had a lower NYHA classification improvement (38.4%vs 69.7%, P<0.001), and a higher deterioration (15.1%vs 10.1, P<0.001)。A baseline eGFR≥60ml/min/1.73m2 with acute renal injury, had a lower improvement in NYHAclassification than those without AKI (58.7%vs 76.6%, P<0.001), a higher NYHA classification deteriortation(12.7% vs 5.7%, P<0.001), stastically different.6.Outcomes affected by basline renal functionBaseline eGFR<60ml/min/1.73m2 had higher mortality than those eGFR≥60ml/min/1.73m2 patients, longer CCU stay. Renal function recovery completely was lower than those with eGFR≥60ml/min/1.73 m2.7 Risk of mortality of patients with AHFAKI and ACRF were risk factor for mortality of ahf patient. Baseline eGFR<60 ml/min/1.73m2, elder aged, NYHA≥class 3, large dose frusemide, cardiopulmonary resuscitation were all risk factors for death of AHF patients.ConclusionsRenal function injury was a severe complication in the population with ADHF and associated with greatly increased mortality during hospitalization, and could incapacitate the survivors because of left renal insufficiency. RIFLE criteria could contribute to predict the patient at a moderate to high risk for mortality and left renal insufficiency. Certain independent predictors such as diabetes mellitus, other organ function failure large dose frusemide could predict patients at a high risk for development of acute renalinjury. NYHA class 4. Shock and additional organs dysfunction were also predictors of mortality in those with acute renalinjury.. Such risk predictors could assist in implementing strategies to prevent RI and acute renalinjury., improve prognosis in patients with acute renalinjury., which should offer better outcomes for patients suffered ADHF.