Renal phenotypes and 1-year mortality after acute decompensation in HFpEF: CKD vs AKI
T Aguiar, I Cruz, C Costa, M Silva, S Carvalho, J Ribeiro, J M Bastos, A BriosaAbstract
Introduction
Heart failure with preserved ejection fraction (HFpEF) is highly prevalent among older, comorbid patients, in whom kidney dysfunction is frequent. It remains unclear whether long-term prognosis is driven predominantly by chronic kidney disease (CKD) or by inhospital acute kidney injury (AKI).
Methods
Retrospective single-centre cohort analysis of 159 sequential chronic HFpEF patients admitted to the hospital due to acute heart failure (AHF). Patients were classified into four renal phenotypes: (1) no kidney dysfunction; (2) AKI only; (3) CKD only; (4) AKI on CKD. The primary endpoint was 1-year all-cause mortality. Secondary endpoints included a 1-year composite all-cause death and heart failure rehospitalisation.
Results
The cohort included 36.9% females with a median age of 79 years. Cardiovascular risk factor (CVRF) distribution was as follows: 56.6% hypertensive, 38.4% diabetic, 29.6% dyslipidaemic, and 2.5% smoker. Major comorbidities recorded were 44.7% atrial fibrillation, 25.2% chronic lung disease, 20.1% coronary artery disease, 14.5% CKD, 6.3% stroke, and 2.5% chronic liver disease. Mean LVEF of 58±8%. Kidney dysfunction was frequently observed (14.5% CKD and 37.1% AKI). On Kaplan-Meier survival curve analysis for the primary endpoint, there were significant differences between the renal phenotypes (log-rank χ²=22.6, p<0.001), with CKD and acute on CKD showing the worst survival. This association was similar for the combined endpoint (logrank χ²=8.7, p=0.033). In multivariate analysis adjusted for sex, age, CVRF and comorbidities, the renal phenotypes maintained their independent predictive value for the primary outcome. While AKI alone was not statistically significant, CKD alone showed a strong association (HR 3.95, p=0.049), with CKD plus AKI conferring the highest risk (HR 4.13, p=0.005). No other variable analysed was independently predictive of the primary outcome. The multivariate analysis results were similar for the secondary composite endpoint.
Conclusions
In our cohort of acute HFpEF, CKD was a major independent predictor of 1-year all-cause mortality. While isolated AKI did not predict events in our cohort, patients with acute on chronic kidney dysfunction represented the highest risk cardiorenal subgroup. These findings support prioritising identification and follow-up of HFpEF patients with underlying CKD, especially when complicated by acute renal dysfunction.For image description, please refer to the figure legend and surrounding text.