Treatment patterns of patients with acute heart failure who develop acute kidney injury

In the present study, we aimed to determine the relationship between therapeutic decisions during the treatment of acute heart failure (AHF) patients who develop acute kidney injury (AKI) and subsequent renal and clinical outcomes.

We studied 277 patients with AHF and AKI, defined as an increase of >0.3 mg/dL in serum creatinine. The physician response to AKI was determined through a treatment composite score that captured changes in medical management in response to AKI, including a reduction (≥50%) or discontinuation of selected medication classes [angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACE-Is/ARBs), beta-blockers, and diuretics] and fluids administration. ACE-Is/ARBs, beta-blockers, and diuretics were reduced or discontinued in 103 (55.4%), 84 (38.9%), and 166 (61.5%), respectively. Fluids were administered to 130 (46.9%) patients. Discontinuation rates of ACE-Is/ARBs, beta-blockers, diuretics, and fluids administration were higher in patients with hypotension (systolic blood pressure < 90 mm Hg; P = 0.001). In a logistic regression model, a composite score > 1 was associated with greater likelihood of renal function recovery (odds ratio 3.47, 95% confidence interval 2.06-5.83; P < 0.0001) but with a smaller reduction in congestion index (P = 0.021). Unadjusted 6 months mortality was higher in patients with a composite treatment score > 1 (hazard ratio 1.71, 95% confidence interval 1.12-2.61; P = 0.01). After adjustments, the treatment composite score was no longer associated with mortality.

Discontinuation or dose reduction of diuretics or neurohormonal blockers may improve renal outcome at the price of less efficient decongestion. Our results emphasize the need for randomized clinical trials that address the treatment of AHF patients with AKI.