Clinical InvestigationsWorsening renal function: What is a clinically meaningful change in creatinine during hospitalization with heart failure?*,**
Section snippets
Study sample
We screened consecutive patients admitted to Yale-New Haven Hospital between March 1996 and September 1998 who were ≥50 years of age and met clinical criteria for presence of HF on admission. To identify eligible patients, admissions were screened daily in 2 phases. First, we identified patients with either an admission diagnosis of HF or radiologic signs of HF on the admission chest x-ray. Second, patients who met either of the above conditions had their medical records reviewed within 3 days
Unadjusted outcomes and sensitivity analysis
Unadjusted associations for each of the cutpoints for WRF and outcomes were tested using the Pearson chi-square test and the Kaplan-Meier log-rank test. We calculated the sensitivity and specificity of all WRF definitions in predicting outcomes at 6 months after discharge.
Mortality and readmission
The effect of various definitions of WRF on adjusted risk ratios and odds ratios (ORs) was also analyzed. Multivariable Cox proportional hazards regression tested whether these definitions of WRF were important independent
Study sample
Patients in the study sample were generally elderly, with a mean age of 72 years (standard deviation [SD] 11). The sample was 51% male and 76% white. The majority of patients had a history of HF (72%) and other cardiovascular disease. Many patients had a history of diabetes (47%) and hospitalization for HF (38%). Mean LVEF was 39% (SD 17), with 47% of patients having an LVEF ≥40%. The mean value for creatinine on admission was 1.8 mg/dL (SD 1.4), and 75% of patients presented with a creatinine
Discussion
WRF during an admission for HF, even if defined as a small elevation in creatinine, is an important, independent prognostic indicator of mortality after discharge. Additionally, the prognostic importance of WRF is consistent even in patients admitted with a normal baseline level creatinine, regardless of peak creatinine values, discharge values, and even after considering other major in-hospital adverse events, including cerebrovascular accident, myocardial infarction, and shock. Our data
Conclusion
Although larger creatinine elevations predict the highest risk of poor outcomes, physicians monitoring HF patients should be aware that even minor changes in renal function could be significant, because an elevation as small as 0.2 mg/dL is still associated with adverse outcomes. This and more extreme elevations in creatinine consistently and powerfully predict death after discharge and are associated with other poor outcomes. A clinically appropriate definition of WRF undoubtedly also depends
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Reprint requests to: Dr. Krumholz, Yale University School of Medicine, 333 Cedar Street, PO Box 208025, New Haven, CT 06520-8025.
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Dr. Watnick was a Robert Wood Johnson Clinical Scholar at Yale University during the time the work was conducted. She is currently affiliated with the Section of Nephrology, Oregon Health Sciences University and Portland VA Hospital.