Ejection fraction-dependent prognostic value of discharge albuminuria in acute decompensated heart failure

Post-discharge risk stratification remains challenging in patients with heart failure (HF) with mildly reduced or preserved ejection fraction (HFmrEF/HFpEF), where natriuretic peptides incompletely capture residual renal and microvascular stress. Albuminuria integrates glomerular and microvascular injury, yet whether its prognostic value depends on measurement timing-admission versus discharge-and whether this relationship differs by ejection fraction (EF) phenotype, has not been established.

In 290 patients hospitalized for acute decompensated HF [126 HF with reduced ejection fraction (HFrEF), 164 HFmrEF/HFpEF], the urine albumin-to-creatinine ratio (UACR) was measured at admission and discharge. The primary outcome was the 1-year composite of all-cause death or HF rehospitalization. Sensitivity analyses sequentially adjusted for individual medication classes, and the interaction between UACR and EF phenotype was formally tested.

UACR decreased markedly during hospitalization (median 96.8 to 24.7 mg/gCr; p < 0.001), yet residual albuminuria was greater in HFmrEF/HFpEF at discharge (28.5 mg/gCr vs 18.7 mg/gCr; p = 0.038). During a 1-year follow-up, 98 patients (34%) experienced the composite endpoint. Per 1-SD increase in log-transformed discharge UACR, discharge UACR was independently associated with outcomes in HFmrEF/HFpEF across all four medication-adjusted models (HR range 1.37-1.40, all p ≤ 0.008), whereas admission UACR lost significance after adjustment. No meaningful associations were observed in HFrEF. The interaction between discharge UACR and EF phenotype was of borderline significance after adjustment (p for interaction = 0.047).

Discharge UACR independently predicts adverse outcomes in HFmrEF/HFpEF, with associations that remained consistent after adjustment for individual HF medication classes. Predischarge UACR measurement may refine post-discharge risk stratification in HFmrEF/HFpEF in addition to natriuretic peptides.