Acute kidney injury and outcomes in acute decompensated heart failure in Korea

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1 Acute kidney injury and outcomes in acute decompensated heart failure in Korea Mi-Seung Shin 1, Seong Woo Han 2, Dong-Ju Choi 3, Eun Seok Jeon 4, Jae-Joong Kim 5, Myeong-Chan Cho 6, Shung Chull Chae 7, Kyu-Hyung Ryu 8, Byung-Hee Oh 9, Myoung Mook Lee 10 (1) Gachon University Gil Hospital, Incheon (2) Korea University Guro Hospital, Seoul (3) Seoul National University Bundang Hospital, Seongnam (4) Sungkyunkwan University, Seoul (5) Asan Medical Center, University of Ulsan College of Medicine, Seoul (6) Chungbuk National University Hospital, Cheongju (7) Kyungpook National University Hospital, Daegu (8) Konkuk University Medical Center, Seoul (9) Seoul National University Hospital, Seoul (10) Dongguk University Hospital, Goyang, Republic of Korea

2 Background Clinical outcomes correlate with renal dysfunction in patients with heart failure. Acute kidney injury (AKI) is a common clinical problem encountered in critically ill patients and predicts an increase in morbidity and mortality. European Journal of Heart Failure 2010;12:32

3 Background The RIFLE (risk, injury, failure, loss, end stage) classification has recently been established as the standard method for evaluating AKI in critically ill patients including those with neurological, cardiovascular, pulmonary, malignant, and gastrointestinal diseases. Contrib Nephrol 2007;156:32 Nephrol Dial Transplant 2008;23:1569

4 Background The RIFLE classification was based on the ratio of the maximum serum creatinine value to the baseline creatinine value. Non-AKI AKI Serum Cr criteria S-Cr < 1.5 x baseline Urine output criteria Risk (Class R) S-Cr > 1.5 x baseline < 0.5 ml/kg/h for 6h Injury (Class I) S-Cr > 2 x baseline < 0.5 ml/kg/h for 12h Failure (Class F) S-Cr > 3 x baseline or > 4 mg/dl with an acute rise > 0.5 mg/dl < 0.3 ml/kg/h for >24h or anuria for 12h Contrib Nephrol 2007;156:32, Nephrol Dial Transplant 2008;23:1569

5 Object We evaluated the relationship between AKI and clinical outcomes in patients with acute decompensated heart failure (ADHF) in Korea using recently established the RIFLE classification.

6 Methods We interrogated the KorHF Registry Database composed of 3,200 patients, which enrolled hospitalized patients with ADHF. Only patients with available data and without chronic renal failure were analyzed (n=3026, 1505 males, 67.6 ± 14.5 years old).

7 Methods We defined AKI as maximal increase in serum creatinine more than 1.5 times of baseline levels according to the RIFLE classification. Baseline serum creatinine levels were calculated by solving the Modification of Diet in Renal Disease (MDRD) equation for serum creatinine assuming a glomerular filtration rate of 75 ml/min/1.73 m 2.

8 Methods The Modification of Diet in Renal Disease (MDRD) equation GFR = 186 x (serum creatinine) x (age) x (if black) x (if female)

9 Characteristics of patients AKI (n=652, 21.5%) Non-AKI (n=2374, 78.5%) P-value Age (years) 71.5 ± ± 14.9 P < 0.01 Male (%) P < 0.01 Etiology Ischemic (%) P < 0.01 Valvular (%) P = Hypertension (%) NS Cardiomyopathy (%) P < 0.01

10 Clinical findings on admission AKI Non-AKI P-value BSA (m2) 1.63 ± ± 0.22 NS Systolic BP (mmhg) ± ± 29.2 P = 0.02 Diastolic BP (mmhg) 76.9 ± ± 17.4 NS Heart rate (b.p.m.) 90.0 ± ± 25.5 NS Sinus rhythm (%) NS Atrial fibrillation (%) P = NYHA III - IV (%) P = LV EF (%) 40.0 ± ± 16.6 NS S-Cr (mg/dl) 2.32 ± ± 0.26 P < 0.01

11 AKI and clinical outcomes AKI Non-AKI P-value ICU stay (days) 5.4 ± ± 7.3 P < 0.01 Hospital stay (days) 16.8 ± ± 13.3 P < 0.01 Mechanical ventilation (cases) Mechanical ventilation (days) 85 (14.2%) 157 (7.4%) P < ± ± 2.8 P = Cost (1000 K.W.) 8759 ± ± 8635 P < 0.01 In-hospital death 86 (13.2%) 127 (5.4%) P < 0.01 Rehospitalization (%) P = 0.028

12 AKI and survival rate Non-AKI AKI Follow up (days)

13 Results The prevalence of AKI in ADHF patients was 21.5%. Body surface area and left ventricular ejection fraction were not significantly different between groups. Patients with AKI showed older age (71.5 ± 11.8 years vs ± 14.9 years, p < 0.01) and more male patients (57.8% vs. 47.5%) compared to patients without AKI.

14 Results The etiology showed significantly higher rate of ischemic heart disease in AKI group (48.4% vs. 34.9%, p < 0.01). Both ICU and hospital stays were longer for patients with AKI (5.4 ± 13.5 and 16.8 ± 29.0 days) compared to non-aki group (2.7 ± 7.3 and 11.4 ± 13.3 days).

15 Results AKI group showed higher rate (14.2% vs. 7.4%, p < 0.01) and longer duration of mechanical ventilation. The cost during hospitalization was significantly higher in AKI group. The in-hospital mortality was significantly higher in AKI group (13.2% vs. 5.4%, p < 0.01).

16 Results One month and 1 year survival rate were significantly lower in AKI group (76.3% and 69.9% vs. 83.9% and 79.0%). Up to 59 months follow-up, survival rate was lower in AKI group (68.6% vs. 83.9%, p < 0.05). Rehospitalization rate was higher in AKI group (30.2% vs. 25.8%, p=0.03).

17 Conclusion AKI was associated with higher mortality, poor prognosis and higher hospitalization cost in patients with ADHF in Korea.