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J Am Coll Cardiol, 2000; 35:681-689
© 2000 by the American College of Cardiology Foundation
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CLINICAL STUDIES

The prognostic implications of renal insufficiency in asymptomatic and symptomatic patients with left ventricular systolic dysfunction

Daniel L. Dries, MD, MPH*, Derek V. Exner, MD, MPH{dagger}, Michael J. Domanski, MD{dagger}, Barry Greenberg, MD{ddagger} and Lynne W. Stevenson, MD, FACC*

* Division of Cardiology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
{dagger} Clinical Trials Research Group, Division of Epidemiology and Clinical Applications, National Heart, Lung and Blood Institute, Bethesda, Maryland, USA
{ddagger} Division of Cardiology, University of California at San Diego, San Diego, California, USA

Manuscript received January 28, 1999; revised manuscript received November 10, 1999, accepted November 15, 1999.

Reprint requests and correspondence: Dr. Daniel L. Dries, Cardiomyopathy Transplant Fellow, Division of Cardiology, Brigham and Women’s Hospital, 75 Francis Street, Boston, Massachusetts 02115

OBJECTIVES

The present analysis examines the prognostic implications of moderate renal insufficiency in patients with asymptomatic and symptomatic left ventricular systolic dysfunction.

BACKGROUND

Chronic elevations in intracardiac filling pressures may lead to progressive ventricular dilation and heart failure progression. The ability to maintain fluid balance and prevent increased intracardiac filling pressures is critically dependent on the adequacy of renal function.

METHODS

This is a retrospective analysis of the Studies of Left Ventricular Dysfunction (SOLVD) Trials, in which moderate renal insufficiency is defined as a baseline creatinine clearance <60 ml/min, as estimated from the Cockroft-Gault equation.

RESULTS

In the SOLVD Prevention Trial, multivariate analyses demonstrated moderate renal insufficiency to be associated with an increased risk for all-cause mortality (Relative Risk [RR] 1.41; p = 0.001), largely explained by an increased risk for pump-failure death (RR 1.68;p = 0.007) and the combined end point death or hospitalization for heart failure (RR 1.33; p = 0.001). Likewise, in the Treatment Trial, multivariate analyses demonstrated moderate renal insufficiency to be associated with an increased risk for all-cause mortality (RR 1.41;p = 0.001), also largely explained by an increased risk for pump-failure death (RR 1.49; p = 0.007) and the combined end point death or hospitalization for heart failure (RR 1.45; p = 0.001).

CONCLUSIONS

Even moderate degrees of renal insufficiency are independently associated with an increased risk for all-cause mortality in patients with heart failure, largely explained by an increased risk of heart failure progression. These data suggest that, rather than simply being a marker of the severity of underlying disease, the adequacy of renal function may be a primary determinant of compensation in patients with heart failure, and therapy capable of improving renal function may delay disease progression.

Abbreviations and Acronyms
  BUN = blood urea nitrogen
  CI = confidence interval
  CrCl = creatinine clearance
  LVEF = left ventricular ejection fraction
  NYHA = New York Heart Association
  RR = relative risk
  SOLVD = Studies of Left Ventricular Dysfunction




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