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Heart failure: the grim reaper of the cardio-renal-metabolic triad
Joakim Österman1, Ehab Al-Sodany1, Ida Haugen Löfman2
1Renal Medicine, Department of Clinical Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
Insights
Heart failure significantly increases mortality and major adverse cardiovascular events (MACE) risk in chronic kidney disease (CKD) patients. These patients are also less likely to initiate kidney replacement therapy (KRT), necessitating targeted interventions.
Area of Science:
- Cardiology
- Nephrology
- Endocrinology
- Public Health
Background:
- Chronic kidney disease (CKD) prognosis is poorly understood in patients with coexisting heart failure (HF) and diabetes mellitus (DM).
- Previous research primarily focused on HF or DM cohorts, leaving a gap in understanding CKD patient outcomes with these comorbidities.
- This study investigates long-term outcomes in CKD patients with overlapping cardio-renal-metabolic conditions.
Purpose of the Study:
- To evaluate the long-term prognosis of chronic kidney disease (CKD) patients with coexisting heart failure (HF) and diabetes mellitus (DM).
- To analyze risks of mortality, major adverse cardiovascular events (MACE), and kidney replacement therapy (KRT) initiation.
- To identify treatment patterns and outcomes in this complex patient group.
Main Methods:
- Analysis of a Swedish national CKD patient cohort (n=27,647) from the Swedish Renal Registry.
- 10-year follow-up assessing all-cause mortality, MACE, and KRT initiation.
- Utilized Cox proportional hazards and competing risk models for risk assessment.
Main Results:
- Patients with CKD and HF (with or without DM) had substantially higher mortality and MACE risks compared to CKD alone.
- Mortality rates after 5 years ranged from 23% (CKD alone) to 55% (CKD/HF/DM).
- 10-year MACE risk was 28% (CKD alone) to 73% (CKD/HF/DM); HF presence significantly increased mortality (HR ~3x) and MACE (SHR ~4x).
- CKD patients with HF were less likely to start KRT, with doubled risk of death before KRT initiation.
Conclusions:
- Heart failure significantly exacerbates mortality and MACE risk in CKD patients, irrespective of diabetes status.
- CKD patients with HF show reduced initiation of kidney replacement therapy (KRT).
- Urgent need for targeted therapeutic strategies and management plans for CKD patients with concurrent HF to improve prognosis.
Aims:
Current understanding of the prognosis for patients with chronic kidney disease (CKD) and overlapping cardio-renal-metabolic components, specifically heart failure (HF) and diabetes mellitus (DM), remains limited. While previous studies have explored the interactions between CKD, HF, and DM, they have predominantly focused on cohorts of HF or DM patients. This study aims to fill this gap by investigating the long-term outcomes and treatment patterns in a cohort of CKD patients, particularly those with coexisting HF and DM.
Methods And Results:
We analysed data from the Swedish national CKD patient cohort, the Swedish Renal Registry, with a follow-up period extending up to 10 years. The study examined the risks of all-cause mortality, major adverse cardiovascular events (MACE)-defined as a composite of non-fatal myocardial infarction, hospitalization for congestive HF, non-fatal stroke, or cardiovascular death-and the initiation of kidney replacement therapy (KRT). Analyses were conducted using Cox proportional hazards and competing risk models. Among the 27 647 patients, 48% had CKD alone, 12% had CKD with HF, 27% had CKD with DM, and 13% had CKD with both HF and DM. After 5 years, mortality rates were 23% for patients with CKD, 30% for those with CKD/DM, 54% for CKD/HF, and 55% for CKD/HF/DM. The 10 year absolute risk of MACE was 28% for CKD alone, 35% for CKD/DM, 67% for CKD/HF, and 73% for CKD/HF/DM. The adjusted hazard ratio (HR) for mortality was approximately three times higher in patients with any HF combination, with HRs of 2.57 [95% confidence interval (CI) 2.43-2.71] for CKD/HF and 3.22 (95% CI 3.05-3.39) for CKD/HF/DM, compared with CKD alone. The impact of HF on MACE prognosis was even more pronounced, with adjusted sub-hazard ratios (SHRs) of 3.33 (95% CI 3.14-3.53) for CKD/HF and 4.26 (95% CI 4.04-4.50) for CKD/HF/DM. Additionally, CKD patients diagnosed with HF were less likely to commence KRT, and the risk of death prior to KRT initiation was roughly twice as high for these groups, with SHRs of 2.05 (95% CI 1.93-2.18) for CKD + HF and 2.43 (95% CI 2.29-2.58) for CKD + HF + DM.
Conclusions:
In a cohort of CKD patients, having HF contributes substantially to increased mortality and the risk of MACE, and these patients are less likely to start KRT. These findings highlight the urgent need for targeted therapeutic strategies and management plans for CKD patients, particularly those with concurrent HF, to enhance patient prognosis.
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