Beruflich Dokumente
Kultur Dokumente
doi:10.1093/eurjhf/hfp169
Aims
The clinical course including the outcome of acute decompensated heart failure (ADHF) correlates with renal dysfunction, but the evaluation of renal function has not yet been standardized. We therefore investigated the relationship between the prognosis of ADHF and acute kidney injury (AKI) evaluated using the risk, injury, failure, loss, end
stage (RIFLE) criteria.
.....................................................................................................................................................................................
Methods
This study assessed 376 consecutive patients with ADHF admitted to the intensive care unit (ICU) (mean age 71.6
and results
years; 238 male). The underlying aetiology was ischaemic heart disease, hypertensive heart disease, cardiomyopathy,
valvular diseases, and other in 124, 70, 60, 107, and 15 patients, respectively. We defined AKI according to the RIFLE
criteria, and the most severe RIFLE classifications during hospitalization were adopted to assess patient outcomes.
The in-hospital mortality was significantly higher among patients with AKI (29 of 275; 10.5%) than in those
without AKI (1 of 101; 1.0%, P 0.0010). Both ICU and hospital stays were longer for patients with AKI
(8.8 + 15.4 vs. 48.6 + 47.6 days), than for patients without (5.0 + 2.8 vs. 25.7 + 16.8 days, P , 0.05 and P , 0.001).
.....................................................................................................................................................................................
Conclusion
Acute kidney injury evaluated by the RIFLE criteria was associated with a poorer outcome for patients with ADHF.
----------------------------------------------------------------------------------------------------------------------------------------------------------Keywords
Introduction
Acute kidney injury (AKI) affects the outcome of patients admitted
to intensive care unit (ICU).1 3 In addition, the outcomes of
acute decompensated heart failure (ADHF) correlate with renal
dysfunction,4,5 however, to date a consensus regarding the most
appropriate methods for evaluating renal function and AKI has
not been reached. The RIFLE criteria have recently been established as the standard method for evaluating AKI in critically ill
patients including those with neurological, cardiovascular, pulmonary, malignant, and gastrointestinal diseases,6,7 but the clinical significance of such evaluations has not been determined in patients
with heart failure. In this study, we therefore investigated the
Methods
Study population
We investigated the clinical course of 376 consecutive patients with
ADHF who were admitted to the ICU in Chiba Hokusoh Hospital,
Nippon Medical School, Japan, between April 2000 and June 2008.
Heart failure was diagnosed based on the Framingham criteria.8
Patients with acute cardiovascular disease such as acute myocardial
infarction (AMI), myocarditis, pericarditis, and Takotsubo cardiomyopathy were excluded from the study. In addition, only the first
* Corresponding author. Tel: 81 476 99 1111, Fax: 81 476 99 1911, Email: hata-n@nms.ac.jp
Published on behalf of the European Society of Cardiology. All rights reserved. & The Author 2010. For permissions please email: journals.permissions@oxfordjournals.org.
33
Data collection
Data were retrospectively retrieved from hospital medical records.
Laboratory data included serum creatinine, daily urine output, and
brain-type natriuretic peptide (BNP) levels during hospitalization.
Age, sex, history of chronic renal insufficiency, and haemodialysis,
aetiology of heart failure, Killip classification of heart failure severity,
and left ventricular ejection fraction measured by cardiac ultrasonography (Teichholz method) were recorded. Furthermore, medications
administered in the ICU, use of acute blood purification therapy, any
heart surgery, duration of ICU and hospital stays, and in-hospital mortality were also evaluated.
Statistical analysis
All continuous data are expressed as means + standard deviation and
the mean differences between groups were analysed using Students
t-test or analysis of variance (ANOVA). Proportional differences
were analysed using the Fisher exact analysis. Categorical variables
were analysed using the x2 test. A P-value of less than 0.05 was considered statistically significant. All data were analysed using StatView
5 software for Windows (SAS Institute, Cary, NC, USA), and SPSS
14.0 J for Windows (SPSS Japan Institute, Tokyo, Japan).
Results
Presence of acute kidney injury during
admission
In the 227 patients without chronic renal insufficiency, baseline
creatinine levels were based on the lowest creatinine values in
75 patients and on CrMDRD in 152 patients. We identified AKI
in 125 patients (33%) with ADHF upon admission, but this
increased to 275 patients (73%) during the hospital stay. Acute
kidney injury developed while hospitalized in 150 of the 251
patients (60%) who were free of AKI upon admission (Figure 1).
The RIFLEadm values of the 151 patients with RIFLEmax Class R
were no AKI and RIFLEmax Class R in 104 and 47 patients, respectively. The 70 patients with RIFLEmax Class I were classified upon
admission as having no AKI (n 23), Class R (n 29), and Class
I (n 18). Moreover, of the 54 patients with RIFLEmax Class F,
23, 14, 7, and 10 were evaluated upon admission as having no
AKI, Class R, Class I, and Class F, respectively. Thirty patients
received renal replacement therapy and were evaluated as having
AKI (Class F). Patients were assigned to the AKI (n 275) and
non-AKI (n 101) groups based on their RIFLEmax values.
Non-AKI
Risk (Class R)
Injury (Class I)
Failure (Class F)
...............................................................................................................................................................................
AKI
34
N. Hata et al.
Figure 1 Acute kidney injury (AKI) was evident in 125 of the 376 patients (33%) with acute exacerbation of heart failure upon admission
(RIFLEadm, upper bar). Acute kidney injury developed during hospitalization in 150 of the 251 patients (60%) without acute kidney injury on
admission. (RIFLEmax, bottom bar).
AKI (n 5 275)
P-value
Age (years)
Gender (male/female)
69.0 + 12.3
82/19
72.5 + 11.5
156/119
0.0087
,0.0001
,0.0001
...............................................................................................................................................................................
44/57
183/92
Aetiology
Ischaemic heart disease
35
89
24
89
0.1278
16
23
48
37
0.7593
0.0382
Other
12
0.7677
0.7110
characteristics upon admission are shown in Table 3; serum creatinine levels, haemodynamics, cardiac rhythm, severity of heart
failure (NYHA and Killip classification), left ventricular ejection
fraction, and serum BNP levels were not significantly different
between the groups.
35
AKI (n 5 275)
P-value
...............................................................................................................................................................................
Serum creatinine (mg/dL)
1.29 + 0.54
1.33 + 0.79
0.6082
163.1 + 40.0
88.8 + 22.0
155.7 + 44.9
84.7 + 24.8
0.1472
0.1542
116.7 + 29.4
113.7 + 32.3
0.4086
Cardiac rhythm
Sinus rhythm
0.7104
67
188
Atrial fibrillation
30
71
0.5117
Ventricular fibrillation
Other
0
4
3
13
0.5671
.0.9999
II
III
17
66
29
172
0.1109
0.6317
IV
18
74
0.0788
NYHA classification
Killip classification
I
13
32
II
41
111
.0.9999
III
IV
40
0
106
9
0.9051
0.1203
No record
LVEF upon admission (%)
BNP upon admission (ng/mL)
0.7230
0.8132
34.3 + 15.3
1001 + 837
36.2 + 16.4
1110 + 1203
0.3343
0.4895
AKI, acute kidney injury; NYHA, New York Heart Association; LVEF, left ventricular ejection fraction; BNP, brain-type natriuretic peptide.
non-AKI
(n 5 101)
AKI
(n 5 275)
P-value
Diureticsa
360 (95.7)
97 (96.0)
263 (95.6)
.0.9999
Vasodilatorsb
Inotropic
agentsc
Temporary
pacing
Ventilator
350 (93.1)
271 (72.1)
91 (90.1)
55 (54.5)
259 (94.2)
178 (64.7)
0.1736
0.0733
12 (3.2)
2 (2.0)
10 (3.6)
0.5267
125 (33.2)
22 (21.8)
103 (37.5)
0.0044
................................................................................
IABP
10 (2.7)
10 (3.6)
0.0682
PCPS
1 (0.2)
1 (0.4)
.0.9999
21 (7.6)
0.0120
Heart surgery
22 (5.9)
1 (1.0)
patient without AKI died. The in-hospital mortality rate was significantly higher in the AKI than in the non-AKI group (10.5 vs.
1.0%. P 0.0010). These outcomes correlated with the RIFLE
criteria and were most significant among Class F of the AKI
group.
Discussion
Definition of acute kidney injury
Several epidemiological studies and clinical trials have used either
simple absolute or relative changes in serum creatinine level as surrogates for changes in kidney function to define acute renal failure.
However, the applicability of serum creatinine levels or other biochemical markers alone is limited.1,14,15 The RIFLE criteria are now
considered the standard method for evaluating AKI in critically ill
patients including those with neurological, cardiovascular, pulmonary, malignant, and gastrointestinal diseases.6,7 In this study, we
evaluated the methodology of the RIFLE criteria in an acutely ill
heart failure population. However, only the creatinine criteria of
the RIFLE classification were evaluated in the present study,
because urine output was influenced by the diuretic therapy administered to the majority of our ADHF patients, and also because
urine output could not be measured in the general wards. Lopes
et al.16 reported that serum creatinine seemed to be a better predictor of mortality than urine output because the former led to a
worse RIFLE class. Patients who had undergone renal replacement
therapy were regarded as RIFLEmax Class F, as described by
Mehta et al.11
36
N. Hata et al.
Mortality (%)
...............................................................................................................................................................................
Non-AKI group
101
5.0 + 2.8
25.7 + 16.8
1.0
AKI group
RIFLEmax Class R
275
151
8.8 + 15.4*
6.3 + 4.2
48.6 + 47.6
37.5 + 20.4
29
0
10.5
0.0
RIFLEmax class I
70
6.4 + 3.4
49.1 + 33.1
4.3
RIFLEmax Class F
54
19.1 + 32.5
79.7 + 88.9
26
49.1
ICU, intensive care unit; AKI, acute kidney injury; R, risk; I, injury; F, failure.
*P , 0.05.
P , 0.0001.
P 0.0010 or P , 0.01.
Study limitations
The ratio of the maximum serum creatinine to baseline creatinine
was underestimated in patients with chronic renal insufficiency due
to high baseline creatinine values. The time course of changes in
the occurrence of AKI was not precisely evaluated. A multi-centre
study should be performed to evaluate the influence of medications administered during the hospital admission. The RIFLE
classification could not be evaluated quickly in our study, therefore
further studies should investigate its ability to predict AKI occurrence at an earlier stage of hospitalization. Although, the RIFLE criteria are clear and easy to understand, they are nevertheless
complex and labour-intensive to calculate and are therefore
mostly used in retrospective evaluations. Colpaert et al.30 stated
that using an electronic alert based on the RIFLE criteria, which
warned the physician in real-time when kidney function is deteriorating, could help to implement these criteria in routine clinical
practice. These authors are currently investigating whether the
implementation of real-time electronic RIFLE alerts can induce
faster therapeutic intervention and are also evaluating the impact
of more timely interventions on the preservation of kidney function and patient outcome. Although no precise resolution of
poor outcomes in ADHF patients with AKI was identified from
this study, use of cardio-renal protective medicines and early
initiation of renal replacement therapy should be recommended
for these patients.
In conclusion, a third of patients with ADHF had AKI upon
admission, but AKI also occurred in 60% of ADHF patients
during hospitalization who did not have AKI at the time of admission. The presence of AKI during hospitalization was associated
with poor outcomes in patients with ADHF, as has been reported
in patients with other critical illnesses. The RIFLE criteria should be
developed into a clinically available and standardized method for
evaluating AKI.
Acknowledgements
We are grateful to the staff of the intensive care unit and the
medical records office in Chiba Hokusoh Hospital, Nippon
Medical School, for collecting the medical data.
Conflict of interest: none declared.
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