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. 2021 Apr;116(4):715-724.
doi: 10.36660/abc.20190465.

Worsening Renal Function and Congestion in Patients with Acute Heart Failure: A Study with Bioelectrical Impedance Vector Analysis (BIVA) and Neutrophil Gelatinase-Associated Lipocalin (NGAL)

[Article in English, Portuguese]
Humberto Villacorta  1 , Aline Sterque Villacorta  1 , Leonardo Simões de Castro Villacorta  1 , Analucia Rampazzo Xavier  1 , Salim Kanaan  1 , Felipe Mafort Rohen  1 , Leonardo Dinis Albuquerque  1 , Daniele Dantas Bastilho  1 , Cecília de Oliveira Cudischevitch  1
Affiliations

Worsening Renal Function and Congestion in Patients with Acute Heart Failure: A Study with Bioelectrical Impedance Vector Analysis (BIVA) and Neutrophil Gelatinase-Associated Lipocalin (NGAL)

[Article in English, Portuguese]
Humberto Villacorta et al. Arq Bras Cardiol. 2021 Apr.

Abstract
in English, Portuguese

Background: Worsening renal function (WRF) is frequently observed in the setting of aggressive diuresis for the treatment of acute decompensated heart failure (ADHF) and is associated with poor outcomes in some studies.

Objective: We sought to assess the relationship of WRF and congestion at discharge with events (cardiac death or heart failure hospitalization).

Methods: Eighty patients with ADHF were studied. WRF was defined by an absolute increase in serum creatinine of ≥0.5 mg/dL from the values measured at the time of admission. B-type natriuretic peptide (BNP) and plasma neutrophil gelatinase-associated lipocalin (NGAL) were measured at admission and at discharge. Congestive state at discharge was assessed using bioelectrical impedance vector analysis (BIVA). Primary endpoint was time to first event defined as a combination of cardiac death or heart failure hospitalization. Receiver operating characteristic (ROC) curve analysis was used to determine the best hydration index cutoff to predict events. Kaplan-Meier event-free survival curves were constructed and compared using the log-rank test. Cox proportional hazards models were used to investigate the association with events. The criterion for determining statistical significance was p<0.05.

Results: Mean age was 60.6±15 years, and 48 (60%) were male. Mean ejection fraction was 35.3±7.8%. WRF occurred in 37.5% of the sample. Baseline creatinine was associated with WRF (p<0.001), but neither admission BNP (p=0.35) nor admission NGAL (p=0.18) was predictor of WRF. Using Cox proportional hazard models, hydration index at discharge calculated with BIVA was significantly associated with events (HR 1.39, 95% CI 1.25-1.54, p<0.0001) but not WRF (HR 2.14, 95% CI 0.62-7.35, p=0.22).

Conclusion: Persistent congestion at discharge was associated with worse outcomes. WRF seems to be related to hemodynamic changes during the decongestion process but not to kidney tubular injuries.

Fundamento: O agravamento da função renal (AFR) é frequentemente observado na terapia agressiva com diuréticos para o tratamento de insuficiência cardíaca aguda descompensada (ICAD) e está associado com piores desfechos em alguns estudos.

Objetivo: Avaliar a relação de AFR e congestão na alta hospitalar com ocorrência de eventos (morte cardíaca ou internação por insuficiência cardíaca).

Métodos: Oitenta pacientes com ICAD foram estudados. O AFR foi definido por um aumento absoluto (≥0,5 mg/dL) nos níveis séricos de creatinina a partir dos valores obtidos na admissão. Concentrações de peptídeo natriurético do tipo B (BNP) e lipocalina associada à gelatinase neutrofílica (NGAL) foram medidas na admissão e na alta hospitalar. Congestão foi avaliada na alta utilizando a análise vetorial de bioimpedância elétrica (BIVA). O desfecho primário foi o tempo para o primeiro evento, definido como uma combinação de morte cardíaca ou hospitalização por insuficiência cardíaca. Análise de curva Característica de Operação do Receptor (curva ROC) foi realizada para determinar o ponto de corte de IH mais adequado para predição de eventos. Curvas Kaplan-Meier de sobrevida livre de eventos foram construídas e comparadas usando o teste de log-rank. Modelos de riscos proporcionais de Cox foram usados para investigar a associação com eventos. O critério para se estabelecer significância estatística foi um p<0.05.

Resultados: A idade média foi 60,6 ± 15,0 anos, e 48 (60%) pacientes eram do sexo masculino. A fração de ejeção média foi 35,3±7,8%. O AFR ocorreu em 37,5% da amostra. A creatinina basal associou-se com AFR (p<0,001), mas nem BNP (p=0,35) nem NGAL (p=0,18) na admissão foram preditores de AFR. Usando modelos de riscos proporcionais de Cox, o índice de hidratação na alta, estimado por BIVA, associou-se significativamente com ocorrência de eventos (HR 1,39; IC95% 1,25-1,54, p<0,0001), mas não com AFR (HR 2,14; IC95% 0,62-7,35, p=0,22).

Conclusão: A congestão persistente na alta associou-se com piores desfechos. O AFR parece estar relacionado com alterações hemodinâmicas durante o processo de descongestionamento, mas não com lesões renais.

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Conflict of interest statement

Potencial Conflito de Interesses

Declaro não haver conflito de interesses pertinentes.

Figures

Figura 1
Figura 1. Fluxograma do estudo.
Figura 2
Figura 2. Análise vetorial de bioimpedância elétrica (BIVA). a) Aparelho de BIVA; b) Os eletrodos são posicionados sobre a mão e o pé direitos do paciente; c) Análise vetorial: os sinais são capturados por alguns segundos e, após a análise, de acordo com o ângulo de fase formado pelo vetor, estima-se o grau de hidratação; d) Grau de hidratação de acordo com o índice de hidratação.
Figura 3
Figura 3. Taxa de sobrevida livre de eventos com base na detecção de agravamento da função renal (AFR) durante a hospitalização, e presença ou não de congestão na alta hospitalar. Grupo = Sem AFR /Sem congestão; 2= AFR/Sem congestão; 3= Sem AFR /Com congestão; e 4= Com AFR/Com congestão (p<0,001); Congestão avaliada pelo índice de hidratação (IH) com análise vetorial de bioimpedância elétrica.
Figura 4
Figura 4. Média de creatinina (Cr) na admissão, pico médio, e média na alta hospitalar em pacientes com e sem eventos. Barras indicam desvio padrão. Valores de p referem-se às comparações entre grupos (Teste t de Student).
Figure 1
Figure 1. Study flowchart.
Figure 2
Figure 2. Bioelectrical impedance vector analysis (BIVA). a) The BIVA machine; b) the electrodes are placed on the patient’s right hand and foot; c) vector analysis: the signs are captured for a few seconds and after analysis, according to the phase angle formed by the vector, the degree of hydration is estimated; d) degree of hydration according to the hydration index
Figure 3
Figure 3. Event-free survival rate based on the detection of WRF during hospitalization and the presence or not of congestion at the time of discharge. 1= No WRF/No congestion; 2= WRF/No congestion; 3= No WRF/Congestion; and 4= WRF/Congestion. Time is depicted as days (p<0.001); Congestion was assessed by hydration index (HI) with bioelectrical impedance vector analysis (BIVA); WRF: worsening renal function.
Figure 4
Figure 4. Mean creatinine (Cr) at admission, peak creatinine, and discharge creatinine in patients with and without events. Bars are standard deviation. P values refer to intergroup comparisons (Students’ t-test).
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