CLINICAL RESEARCH: HEART FAILURE
Renal Impairment and Outcomes in Heart Failure
Systematic Review and Meta-Analysis
Grace L. Smith, MD, MPH*,1,
Judith H. Lichtman, PhD, MPH ,
Michael B. Bracken, PhD, MPH,
Michael G. Shlipak, MD, MPH ,||,
Christopher O. Phillips, MD, MPH¶,
Paul DiCapua, BS* and
Harlan M. Krumholz, MD, SM, FACC*,, ,#,*
* Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, Connecticut
Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, New Haven, Connecticut
General Internal Medicine Section, Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, California
|| Department of Medicine, University of California, San Francisco, California
¶ Department of General Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
# Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut
Manuscript received July 26, 2005;
revised manuscript received November 18, 2005,
accepted November 21, 2005.
* Reprint requests and correspondence: Dr. Harlan M. Krumholz, Robert Wood Johnson Clinical Scholars Program, Yale University School of Medicine, Sterling Hall of Medicine (SHM), I-Wing, Suite 456, 333 Cedar Street, New Haven, Connecticut 06520. (Email: harlan.krumholz{at}yale.edu).
OBJECTIVES: We estimated the prevalence of renal impairment in heart failure (HF) patients and the magnitude of associated mortality risk using a systematic review of published studies.
BACKGROUND: Renal impairment in HF patients is associated with excess mortality, although precise risk estimates are unclear.
METHODS: A systematic search of MEDLINE (through May 2005) identified 16 studies characterizing the association between renal impairment and mortality in 80,098 hospitalized and non-hospitalized HF patients. All-cause mortality risks associated with any renal impairment (creatinine >1.0 mg/dl, creatinine clearance [CrCl] or estimated glomerular filtration rate [eGFR] <90 ml/min, or cystatin-C >1.03 mg/dl) and moderate to severe impairment (creatinine  1.5, CrCl or eGFR <53, or cystatin-C 1.56) were estimated using fixed-effects meta-analysis.
RESULTS: A total of 63% of patients had any renal impairment, and 29% had moderate to severe impairment. After follow-up 1 year, 38% of patients with any renal impairment and 51% with moderate to severe impairment died versus 24% without impairment. Adjusted all-cause mortality was increased for patients with any impairment (hazard ratio [HR] = 1.56; 95% confidence interval [CI] 1.53 to 1.60, p < 0.001) and moderate to severe impairment (HR = 2.31; 95% CI 2.18 to 2.44, p < 0.001). Mortality worsened incrementally across the range of renal function, with 15% (95% CI 14% to 17%) increased risk for every 0.5 mg/dl increase in creatinine and 7% (95% CI 4% to 10%) increased risk for every 10 ml/min decrease in eGFR.
CONCLUSIONS: Renal impairment is common among HF patients and confers excess mortality. Renal function should be considered in risk stratification and evaluation of therapeutic strategies for HF patients.
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Abbreviations and Acronyms
| | ACE = angiotensin-converting enzyme | | CI = confidence interval | | CrCl = creatinine clearance | | eGFR = estimated glomerular filtration rate | | HF = heart failure | | HR = hazard ratio | | NYHA = New York Heart Association | | OR = odds ratio | | RR = risk ratio |
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