Role of renal function in patients with advanced heart failure: insights from the help-hf registry

Abstract

Abstract Background Chronic kidney disease (CKD) and heart failure (HF) strongly interact in determining patients prognosis. However, the prevalence and impact of CKD in advanced HF is still poorly characterized. Objective To determine the prevalence and prognostic impact of CKD and how estimated glomerular filtration rate (eGFR) might limit the use of guideline directed medical therapy in a large cohort of HF patients with at least one high-risk I NEED HELP marker. Methods 1120 patients enrolled in the HELP-HF registry were included in the analysis; eGFR was calculated according to the Chronic Kidney Disease Epidemiology Collaboration formula. Patients were stratified according to eGFR into three categories (> 60 ml/min, 30-60 ml/min, <30 ml/min). The primary endpoint was a composite of all-cause death and HF-hospitalization. Secondary endpoints were all-cause death, HF-hospitalization and cardiovascular death. Results 291 patients (25.98%) had an eGFR>60 ml/min, whereas 497 (44.37%) had eGFR between 30 and 60 ml/min and 332 (29.64%) had <30 ml/min. The risk of the primary endpoint was increased in patients with worse renal function (eGFR 30-60, HR 1.34, 95%CI 1.05-1.71, p = 0.017; eGFR<30, HR 1.88, 95%CI 1.47-2.42, p<0.001), whereas only patients with eGFR<30 ml/min demonstrated higher risk of all-cause death (HR = 2.36, 95%CI 1.68-3.31, p<0.001) and CV death (HR = 3.08, 95%CI 2.00-4.75, p<0.001). No difference in HF hospitalizations was seen with respect to patients with eGFR>60 ml/min. Once analyzed as a continuous variable, eGFR was significantly associated with each outcome. The impact of CKD was also confirmed in patients fulfilling the 2018 ESC-HFA definition of advanced HF. Logistic regression showed that patients with lower eGFR and with HF with reduced (HFrEF) and mildly reduced ejection fraction (HFmrEF) were less frequently discharged on maximal tolerated dose of mineral corticoid receptor antagonists (p= 0.001 for HrEF, p= 0.013 for HFmrEF), while lower eGFR was associated with less frequent use of maximal tolerated dose of a renin-angiotensin inhibitors (including angiotensin receptor-neprilysin inhibitors) only among patients with HFmrEF (p = 0.018). Conclusions Chronic kidney disease is highly prevalent among patients with advanced HF and impacts on patients’ prognosis and survival. The use of GDMT was significantly limited in patients with lower eGFR only in patients with HFrEF and HFmrEF.