Sex differences in prognostic factors for all-cause mortality in people with CKD hospitalized with HF
T Duk, S A E Peters, M J Boonstra, D E Grobbee, F W Asselbergs, A UijlAbstract
Introduction
Patients with heart failure (HF) have a high risk of mortality, with approximately two thirds of patients dying within five years of diagnosis. One of the most common comorbidities in this population is chronic kidney disease (CKD), which is present in up to half of patients with HF and is associated with a substantially worse prognosis. HF and CKD frequently coexist and complicate clinical management. Important sex differences exist in the prevalence and severity of CKD among patients with HF, with women more often having milder kidney dysfunction and men more frequently presenting with advanced CKD. These differences may contribute to variation in prognosis and support the need for sex-specific risk stratification in patients with HF and CKD.
Purpose
To assess sex differences in all-cause mortality in HF patients with concomitant CKD in a tertiary hospital in the Netherlands.
Methods
Adult patients with HF and concomitant CKD hospitalized for HF between 1-1-2015 and 15-12-2025 in a tertiary hospital in the Netherlands were included. International Classification of Disease codes (version 9 and 10) were used to define HF, CKD and prognostic factors. Risk of death was assessed within the first year after hospital discharge and described using unadjusted women-to-men risk ratios (RRs) and risk differences (RDs) across relevant prognostic factors. Sex differences were considered clinically relevant if the absolute RR ≥20% and the absolute RD ≥2%.
Results
In total, we included 2,496 patients (44% women). At discharge, 28% of women and 32% of men had an eGFR <30 mL/min/1.73m2. One-year mortality was 26% in women and 32% in men, increasing respectively to 35% and 45% among those with an eGFR <30 mL/min/1.73m2, compared with 22% and 26% among those with an eGFR ≥30 mL/min/1.73m2. Sex differences in one-year all-cause mortality varied across categories of clinical characteristics (Figure 1). Women had a higher mortality risk than men among patients with CKD stage 1 at discharge (RR: 2.06, RD: 24%). In contrast, men had a higher mortality risk than women among patients with hyperkalaemia (RR: 0.67, RD: -19%), dementia (RR: 0.61, RD: -19%), overweight (BMI 25–30 kg/m²) (RR: 0.56, RD: -14%), prior stroke (RR: 0.65, RD: -15%), diabetes mellitus (RR: 0.66, RD: -11%), and more advanced stages of CKD at admission or discharge. Sex differences were also observed according to HF pharmacotherapy, with lower mortality among women prescribed angiotensin receptor blockers (RR: 0.73, RD: -5%) or SGLT2 inhibitors (RR: 0.57, RD: -7%) at discharge compared with men.
Conclusions
These findings demonstrate that sex differences in one-year mortality vary across clinically relevant characteristics, suggesting heterogeneity in prognostic profiles between women and men. This supports the development of sex-specific risk prediction models to improve individualised prognostic assessment in patients hospitalised for HF with concomitant CKD.Sex differences in HF characteristics.For image description, please refer to the figure legend and surrounding text.