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. 2025 Aug;20(5):1553-1564.
doi: 10.1007/s11739-024-03796-0. Epub 2024 Oct 29.

Relationship between clinical congestion and worsening renal function after intravenous initiation of furosemide in patients with acute heart failure

Begoña Espinosa #  1 , Lluís Llauger #  2 , Víctor Gil  3 , Rosa Escoda  3 , Javier Jacob  4 , Alfons Aguirre  5 , Enrique Martín Mojarro  6 , Josep Tost  7   8 , Aitor Alquézar-Arbé  9   10 , María Luisa López-Grima  11 , Javier Millán  12 , Marta Massó  3 , Guillem Suñén Cuquerella  5 , Francesc Pagán  3 , Julio Núñez  13 , Jeroen Dauw  14 , Wilfried Müllens  14 , Pere Llorens  1 , Òscar Miró  15 ; ICA-SEMES group
Collaborators, Affiliations

Relationship between clinical congestion and worsening renal function after intravenous initiation of furosemide in patients with acute heart failure

Begoña Espinosa et al. Intern Emerg Med. 2025 Aug.

Abstract

To investigate if worsening renal function (WRF) appearing in some patients with acute heart failure (AHF) after intravenous furosemide initiation is influenced by severity of congestion. We conducted a retrospective secondary analysis of consecutive patients diagnosed with AHF and prospectively included in 10 Spanish emergency departments (EDs) for whom serum creatinine at ED arrival and after 2-7 days of intravenous furosemide initiation were available. Congestion was clinically evaluated by identification of 7 signs/symptoms and by chest X-ray. The outcome was WRF, defined as a delta-creatinine ≥ 0.3 mg/dL. Risk of WRF according to congestion was estimated in models adjusted by patient baseline characteristics and vitals at ED arrival, and interaction was also investigated. We included 3027 patients (median age 82 years, 56% women), and 657 (21.7%) presented WRF after intravenous furosemide initiation. When signs/symptoms were individually considered, only lower limbs edema was associated with decreased risk of WRF (20.1% vs. 24.8%; OR = 0.76, 95%CI = 0.64-0.91). After adjustment, lower limbs edema persisted inversely associated with WRF (aOR = 0.78, 95%CI = 0.65-0.94), with significant lower risk for patients ≤ 80 years and without chronic kidney disease, functional limitation, and hypoxemia (p for interaction 0.01, 0.04, 0.02 and 0.03, respectively). Neither degree of clinical congestion (number of signs/symptoms of congestion) nor radiological congestion in chest X-ray were related to WRF. Worsening renal function was associated with a higher 1-year all-cause mortality (40.1% vs 34.6%; HR = 1.27, 1.10-1.46; aHR = 1.331, 1.151-1.540). In patients with WRF, liver cirrhosis, chronic treatment with loop diuretics and renin-angiotensin system inhibitors, age (> 80 years), dementia, heart valve disease and NYHA class III-IV were associated with higher mortality. Intravenous furosemide initiation in patients with AHF without lower limbs edema must be cautious, as they are at increasing risk of developing WRF during the next following days, which in turn is associated with a higher 1-year mortality.

Keywords: Acute heart failure; Congestion; Furosemide; Lower limb edema; Worsening renal function.

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Conflict of interest statement

Declarations. Conflict of interest: This study has been funded by Instituto de Salud Carlos III (ISCIII) through the project PI18/00393 and co-funded by the European Union. The ICA-Research Group has PI18/00393 and co-funded by the European Union. The ICA-Research Group has of the study, patient inclusion, data analysis, discussion and final conclusions were of the study, patient inclusion, data analysis, discussion and final conclusions were exclusively carried out by the authors with no participation of the granters. The authors declare that they have no conflict of interest. Ethical approval: The EAHFE Registry protocol was approved by central Ethics Committees at the Hospital Universitario Central de Asturias (Oviedo, Spain, reference numbers 49/2010, 69/2011, Universitario Central de Asturias (Oviedo, Spain, reference numbers 49/2010, 69/2011, reference number 2018/0233). Due to the non-interventional design of the registry, reference number 2018/0233). Due to the non-interventional design of the registry, notification to the local Ethical Committees. All participating patients gave informed consent to be included in the registry and to be contacted for follow-up. The present study was carried out in strict compliance with the principles of the Declaration ofHelsinki. Informed consent: All participants provided informed consent prior to their participation.

References

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