Heart failure subphenotypes based on mean arterial pressure trajectory identify patients at increased risk of acute kidney injury

Abstract

Background: Acute kidney injury (AKI) is a common complication in heart failure (HF) patients. Patients with heart failure who experience renal injury tend to have a poor prognosis. The objective of this study is to examine the correlation between the occurrence of AKI in heart failure patients and different mean arterial pressure (MAP) trajectories, with the goal of improving early identification and intervention for AKI.

Methods: A retrospective study was conducted on patients with heart failure using data from the Medical Information Mart for Intensive Care IV (MIMIC-IV). We utilized the group-based trajectory modeling (GBTM) method to classify the 24-hour MAP change trajectories in heart failure patients. The occurrence of AKI within the first 7 days of intensive care unit (ICU) admission was considered the outcome. The impact of MAP trajectories on AKI occurrence in heart failure patients was analyzed using Cox proportional hazards models, competing risk models, and doubly robust estimation methods.

Results: A cohort of 8,502 HF patients was analyzed, with their 24-hour MAP trajectories categorized into five groups: Low MAP group (Class 1), Medium MAP group (Class 2), Low-medium MAP group (Class 3), High-to-low MAP group (Class 4), and High MAP group (Class 5). The results from the doubly robust analysis revealed that Class 4 exhibited a significantly increased AKI risk than Class 3 (HR 1.284, 95% CI 1.085-1.521, p = 0.003; HR 1.271, 95% CI 1.074-1.505, p = 0.005). Conversely, the risks of Class 2 were significantly lower than those of Class 3 (HR 0.846, 95% CI 0.745-0.960, p = 0.009; HR 0.879, 95% CI 0.774-0.998, p = 0.047).

Conclusions: The 24-hour MAP trajectory in HF patients influences the risk of AKI. A rapid decrease in MAP (Class 4) is associated with a higher AKI risk, while maintaining MAP at a moderate level (Class 2) significantly reduces this risk. Therefore, closely monitoring MAP changes is crucial for preventing AKI in HF.

Keywords: Acute kidney injury; doubly robust estimation; group-based trajectory modeling; heart failure; mean arterial pressure.

Figure 1.

Flow diagram of the patient selection process.

Figure 2.

Five classes identified by trajectories of MAP.

Figure 3.

Cumulative incidence curves by Kaplan–Meier method. (A) Before IPTW of AKI, (B) After IPTW of AKI.

Figure 4.

The SMDs of baseline characteristics between three groups.

Figure 5.

Cumulative incidence curves by Kaplan–Meier method. (A) Before IPTW of 28-day mortality, (B) Before IPTW of 90-day mortality, (C) After IPTW of 28-day mortality, (D) After IPTW of 90-day mortality.