Effect of right ventricular function and venous congestion on cardiorenal interactions during the treatment of decompensated heart failure

Abstract

Recent reports have demonstrated the adverse effects of venous congestion on renal function (RF) and challenged the assumption that worsening RF is driven by decreased cardiac output (CO). We hypothesized that diuresis in patients with right ventricular (RV) dysfunction, despite decreased CO, would lead to a decrease in venous congestion and resultant improvement in RF. We reviewed consecutive admissions with a discharge diagnosis of heart failure. RV function was assessed by multiple echocardiographic methods and those with >or=2 measurements of RV dysfunction were considered to have significant RV dysfunction. Worsening RF was defined as an increase in creatinine of >or=0.3 mg/dl and improved RF as improvement in glomerular filtration rate >or=25%. A total of 141 admissions met eligibility criteria; 34% developed worsening RF. Venous congestion was more common in those with RV dysfunction (odds ratio [OR] 3.3, p = 0.009). All measurements of RV dysfunction excluding RV dilation correlated with CO (p <0.05). Significant RV dysfunction predicted a lower incidence of worsening RF (OR 0.21, p <0.001) and a higher incidence of improved RF (OR 6.4, p <0.001). CO emerged as a significant predictor of change in glomerular filtration rate during hospitalization in those without significant RV dysfunction (r = 0.38, p <0.001). In conclusion, RV dysfunction is a strong predictor of improved renal outcomes in patients with acute decompensated heart failure, an effect likely mediated by relief of venous congestion.

Figure 1

Incidence of improved worsening RF by number of positive measures of RV dysfunction (A) Improved RF, defined as ≥ 25% increase in glomerular filtration rate (B) Worsening renal function, defined as an increase in serum creatinine ≥ 0.3 mg/dL. RF=renal function. RV= Right ventricle.

Figure 1

Incidence of improved worsening RF by number of positive measures of RV dysfunction (A) Improved RF, defined as ≥ 25% increase in glomerular filtration rate (B) Worsening renal function, defined as an increase in serum creatinine ≥ 0.3 mg/dL. RF=renal function. RV= Right ventricle.

Figure 2

CO grouped by worsening RF. (A) CO grouped by worsening RF in total cohort. (B) CO grouped by worsening RF and RV dysfunction. No RV dysfunction defined as absence of any RV dysfunction measure correlating with CO (tricuspid annular plane systolic excursion, fractional area change, or qualitative RV dysfunction). p values represent between group differences. CO =cardiac output. RF=renal function. RV= Right ventricle.

Figure 2

CO grouped by worsening RF. (A) CO grouped by worsening RF in total cohort. (B) CO grouped by worsening RF and RV dysfunction. No RV dysfunction defined as absence of any RV dysfunction measure correlating with CO (tricuspid annular plane systolic excursion, fractional area change, or qualitative RV dysfunction). p values represent between group differences. CO =cardiac output. RF=renal function. RV= Right ventricle.