Importance of venous congestion for worsening of renal function in advanced decompensated heart failure

Abstract

Objectives: To determine whether venous congestion, rather than impairment of cardiac output, is primarily associated with the development of worsening renal function (WRF) in patients with advanced decompensated heart failure (ADHF).

Background: Reduced cardiac output is traditionally believed to be the main determinant of WRF in patients with ADHF.

Methods: A total of 145 consecutive patients admitted with ADHF treated with intensive medical therapy guided by pulmonary artery catheter were studied. We defined WRF as an increase of serum creatinine >/=0.3 mg/dl during hospitalization.

Results: In the study cohort (age 57 +/- 14 years, cardiac index 1.9 +/- 0.6 l/min/m(2), left ventricular ejection fraction 20 +/- 8%, serum creatinine 1.7 +/- 0.9 mg/dl), 58 patients (40%) developed WRF. Patients who developed WRF had a greater central venous pressure (CVP) on admission (18 +/- 7 mm Hg vs. 12 +/- 6 mm Hg, p < 0.001) and after intensive medical therapy (11 +/- 8 mm Hg vs. 8 +/- 5 mm Hg, p = 0.04). The development of WRF occurred less frequently in patients who achieved a CVP <8 mm Hg (p = 0.01). Furthermore, the ability of CVP to stratify risk for development of WRF was apparent across the spectrum of systemic blood pressure, pulmonary capillary wedge pressure, cardiac index, and estimated glomerular filtration rates.

Conclusions: Venous congestion is the most important hemodynamic factor driving WRF in decompensated patients with advanced heart failure.

Conflict of interest statement

Disclosure: There are no financial conflicts of interest and this project did not receive funding support.

Figures

Figure 1. Prevalence of worsening renal function during hospitalization according to categories of admission central venous pressure, cardiac index, systolic blood pressure and pulmonary capillary wedge pressure

Abbreviations: CVP = central venous pressure, Cr = serum creatinine, CI = cardiac index, SBP = systolic blood pressure, PCWP = pulmonary capillary wedge pressure.

Figure 2

ROC curves for central venous pressure (CVP) and cardiac index (CI) on admission for worsening renal function development.

Figure 3. Relative contributions of central venous pressure (CVP) and cardiac index (CI) to glomerular filtration rate (GFR) at time of pulmonary artery catheter removal

Error bars represent 95% confidence interval. Cut-off values for CI = 2.4 l/min.m2 and CVP = 8 mmHg.