Rates of Reversal of Volume Overload in Hospitalized Acute Heart Failure: Association With Long-term Kidney Function.

Abstract Rationale and Objective Achievement of decongestion in acute heart failure (AHF) is associated with improved survival and cardiovascular outcomes, but can be associated with acute declines in estimated glomerular filtration rate (eGFR). We sought to examine whether rate of in-hospital decongestion is associated with longer term kidney function decline. Study Design Post hoc analysis of trial data. Settings & Participants Patients with ≥2 measures of kidney function (n=3,500) from the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study With Tolvaptan (EVEREST) trial. Exposure In-hospital rate of change in assessments of volume overload, including b-type natriuretic peptide (BNP), N-terminal pro b-type natriuretic peptide (NT-proBNP) and clinical congestion score (0-12); and rate of change in hemoconcentration including measures of hematocrit, albumin and total protein. Outcomes Incident chronic kidney disease (CKD) Stage ≥4 (defined by a new eGFR 40%. Analytical Approach Multivariable cause-specific hazards models. Results Over median 10-month follow-up, faster decreases in volume overload and more rapid increases in hemoconcentration were associated with decreased risk of incident CKD Stage ≥4 and eGFR decline of >40%. In adjusted analyses, for every 6% faster decline in BNP per week, there was a 32% lower risk of both incident CKD Stage ≥4 (HR=0.68, 95% CI 0.58, 0.79) and eGFR decline by >40% (HR=0.68, 95% CI 0.57, 0.80). For every 1% faster increase per week in absolute hematocrit, there was a lower risk for both incident CKD Stage ≥4 (HR=0.73 [0.64, 0.84]) and eGFR decline by >40% (HR=0.82 [0.71, 0.95]), with results consistent for other biomarkers. Limitations Possibility of residual confounding. Conclusion These results provide reassurance that more rapid decongestion in patients with AHF do not increase the risk of adverse kidney outcomes in patients with HF.