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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

View larger version (43K): [in a new window]   Figure 1 Quality of Reporting of Meta-Analyses (QUOROM) flow diagram for study selection. HF = heart failure.

View larger version (17K): [in a new window]   Figure 2 Combined adjusted all-cause mortality risk: any renal impairment. *Compares 44,455 patients with any renal impairment versus 22,625 without renal impairment. CI = confidence interval; HR = hazard ratio.

View larger version (8K): [in a new window]   Figure 3 Detecting no publication bias: funnel plot for adjusted all-cause mortality risk.

View larger version (14K): [in a new window]   Figure 4 Combined adjusted all-cause mortality risk: severe renal impairment. *Compares 17,979 patients with moderate to severe renal impairment versus 22,625 without renal impairment. CI = confidence interval; HR = hazard ratio.

View larger version (25K): [in a new window]   Figure 5 Incremental and early mortality risks. *Total HR = 1.20 (1.11, 1.30) when Smith et al. (5) (2005) removed (disproportionately large sample size of hospitalized elderly) with heterogeneity X2, p = 0.84. Results not significantly different when using Smilde et al. (24) for PRIME-II results instead of Hillege et al. (2) or when Akhter et al. (22) removed (New York Heart Association functional class IV only). CI = confidence interval; HR = hazard ratio.