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The paradox of transient worsening renal function in patients with acute heart failure: the role of B-type natriuretic peptide and diuretic response

Ruocco, Gaetano; Nuti, Ranuccio; Giambelluca, Amalia; Evangelista, Isabella; De Vivo, Oreste; Daniello, Cosimo; Palazzuoli, Alberto

Journal of Cardiovascular Medicine: November 2017 - Volume 18 - Issue 11 - p 851–858
doi: 10.2459/JCM.0000000000000546
Research articles: Acute heart failure

Aims: Worsening renal function (WRF) occurs in one-third of patients hospitalized for acute decompensated heart failure. Recently, WRF was categorized in two subtypes: persistent and transient WRF. Thus, we sought to investigate the different prognostic impact of persistent vs. transient WRF; we also evaluate the relation of two WRF phenotypes with congestion, B-type natriuretic peptide (BNP) changes, and diuretic response at discharge.

Methods: The prospective was a single centre study including patients screened for interventional Diur-heart failure Trial (NCT01441245). Patients were eligible if they were admitted with a primary diagnosis of acute heart failure with evidence of volume overload. Persistent WRF was defined as a sustained creatinine increase by at least 0.3 mg/dl throughout the hospitalisation; transient WRF was defined as creatinine increase by at least 0.3 mg/dl within 72 h and a return to baseline levels at discharge. Patients were followed for 6 months after discharge.

Results: Our population included 192 acute decompensated heart failure patients. In total, 61 patients developed persistent WRF and 29 developed transient WRF. Patients with persistent WRF showed a lower mean urine output with respect to the transient WRF group and patients with preserved renal function (1618 ± 374 vs. 2132 ± 392 vs. 2075 ± 442 ml; P < 0.001). Similarly, patients with transient WRF demonstrated a higher rate of BNP decrease more than 30% than seen in patients with stable creatinine levels and in the persistent WRF group (95 vs. 76 vs. 54%; P = 0.001). Univariate Cox regression analysis demonstrated that BNP decrease less than 30% [HR 2.15 (1.40–3.40); P < 0.001] and persistent WRF [HR 1.70 (1.11–2.61); P = 0.01] were related to poor outcome; conversely, transient WRF should be considered as a protective factor [HR 0.42 (0.19–0.93); P = 0.03]. In the multivariable model, only persistent WRF appeared to be related to poor prognosis [HR 1.61 (1.02–2.57); P = 0.04].

Conclusion: WRF occurring during hospitalization has a different significance: transient deterioration appears to be associated with a favourable clinical course; conversely, persistent WRF is related to poor outcome.

Cardiovascular Diseases Unit, Department of Internal Medicine, University of Siena, Siena, Italy

Correspondence to Alberto Palazzuoli, MD, PhD, Department of Internal Medicine, Le Scotte Hospital, University of Siena, Siena, 53100, Italy Tel: +39577585363; fax: +39577233480; e-mail:

Received 21 March, 2017

Revised 20 June, 2017

Accepted 26 June, 2017

© 2017 Italian Federation of Cardiology. All rights reserved.