Kidney injury in patients with heart failure-related cardiogenic shock: Results from an international, multicentre cohort study

Abstract

Aims: Heart failure-related cardiogenic shock (HF-CS) accounts for about half of CS cases, with a paucity of data regarding the role of kidney injury in this subset. This study aims to evaluate patient characteristics and outcome associated with renal function in patients with HF-CS.

Methods and results: In this multicentre, international, retrospective study, patients with HF-CS from 16 tertiary care centres in five countries were enrolled between 2010 and 2021. To investigate differences in clinical presentation, complications, and 30-day mortality, based on renal function, adjusted logistic and Cox regression models were fitted. Among 1010 HF-CS patients, the median age was 64 (interquartile range [IQR] 52-75) years, with 71.7% being male. Median baseline creatinine was 1.7 (IQR 1.2-2.5) mg/dl, corresponding to an estimated glomerular filtration rate (eGFR) of 41.0 (IQR 25.2-62.2) ml/min/1.73 m². In patients with acute kidney injury (AKI), 30-day mortality increased with AKI stages (no AKI 41.7%, AKI stage 1 43.3%, AKI stage 2 50.0%, AKI stage 3 63.7%; adjusted hazard ratio [HR] for AKI stage 3 1.97, 95% confidence interval [CI] 1.56-2.48, p < 0.001). Similarly, severe renal dysfunction (eGFR ≤ median) was associated with a 21% higher 30-day mortality risk (61.0% vs. 40.1%; adjusted HR 1.48, 95% CI 1.20-1.84, p < 0.001). Sepsis and bleeding were associated with both AKI and renal dysfunction, even after adjustment.

Conclusions: In HF-CS, kidney injury is associated with higher 30-day mortality, potentially mediated by bleeding and sepsis. These findings support the consideration of kidney function as a prognostic marker and call for the development and evaluation of kidney-restoring adjunct interventions in HF-CS.

Keywords: Cardiogenic shock; Heart failure; Kidney function; Kidney injury; Non‐AMI CS.

Figure 1

Associations between demographics, medical history, clinical presentation, and renal dysfunction or acute kidney injury. Odds ratio calculated by mixed effects logistic regressions, adjusted for age, sex, lactate, pH, and prior cardiopulmonary resuscitation (CPR). Definition details of renal dysfunction (RDgfr) and acute kidney injury (AKIcrea) are provided in online supplementary Table  S1 . CI, confidence interval; CS, cardiogenic shock; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure with reduced ejection fraction; SCAI, Society for Cardiovascular Angiography and Interventions.

Figure 2

Creatinine trajectories from baseline to day 7, stratified by median baseline creatinine (A), and with versus without mechanical circulatory support (MCS) use (B). **p < 0.01; ***p < 0.001.

Figure 3

Kaplan–Meier estimates for 30‐day all‐cause mortality in patients with versus without renal dysfunction (RD), acute kidney injury (AKI), or renal replacement therapy (RRT). (A) RDcrea, comparison of patients based on median baseline creatinine levels. (B) RDgfr, comparison of patients based on median baseline estimated glomerular filtration rate (eGFR). (C) AKIcrea, comparison of patients with AKI stage 0 versus 1 versus 2 versus 3 (definitions of AKI stages are provided in online supplementary Table  S1 ). (D) Comparison of patients with versus no use of RRT.

Figure 4

Associations between in‐hospital complications and renal dysfunction or acute kidney injury. Odds ratio calculated by mixed effects logistic regressions, adjusted for age, sex, lactate, pH, and prior cardiopulmonary resuscitation. Definition details of renal dysfunction (RDgfr) and acute kidney injury (AKIcrea) are provided in online supplementary Table  S1 . CI, confidence interval. *Renal replacement therapy is included in the acute kidney injury stage 3 definition.