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. 2025 May 1;6(5):728-738.
doi: 10.34067/KID.0000000703. Epub 2025 Jan 17.

Novel Hemodynamic Markers and Kidney Function in Patients with Acute Decompensated Heart Failure

Marcelle Tuttle  1   2 , Run Banlengchit  3 , Hocine Tighiouart  1   4 , Jeffrey M Testani  5 , Amanda I Moises  1 , Tatsufumi Oka  6 , Katie Ferguson  1 , Hannah Sarnak  1 , Callum Harding  2   4 , Michael S Kiernan  1 , Mark J Sarnak  1 , Wendy McCallum  1
Affiliations

Novel Hemodynamic Markers and Kidney Function in Patients with Acute Decompensated Heart Failure

Marcelle Tuttle et al. Kidney360. .

Abstract

Key Points:

  1. Lower pulmonary artery pulsatility index is associated with increased risk of dialysis in patients with heart failure.

  2. No association was demonstrated between aortic pulsatility index and kidney outcomes.

Background: Patients admitted with acute decompensated heart failure are vulnerable to declines in kidney function, but the exact mechanisms are unknown. Two novel hemodynamic markers, pulmonary artery pulsatility index (PAPI) and aortic pulsatility index (API), represent composite right and left ventricular function, respectively.

Methods: Consecutive unique patient admissions for acute decompensated heart failure to a single quaternary medical center with placement of a pulmonary artery catheter between 2015 and 2021 were reviewed. Cubic spline and linear regression models were used to examine the association between these markers with baseline eGFR and in-hospital eGFR slope. Multivariate Cox proportional hazards models were used to examine the association between PAPI and API with the need for dialysis by linkage of a national database. Covariates included demographics, comorbid conditions, home medications, and baseline eGFR.

Results: The cohort included N=753 patients with mean (SD) age of 62.2 (14.4) years and eGFR of 58.0 (27.1) ml/min per 1.73 m2. For every halving of PAPI, there was a 3.3 (95% confidence interval [CI], 1.5 to 5.1) ml/min per 1.73 m2 lower baseline eGFR and a 0.78 (95% CI, 0.32 to 1.25) ml/min per 1.73 m2 per week lower in-hospital eGFR slope. Over a median follow-up time of 30.3 months, lower PAPI was associated with higher hazard of dialysis during the follow-up period (hazard ratio, 1.44 [95% CI, 1.06 to 1.96] per halving). There was no association between API with baseline eGFR, in-hospital eGFR slope, or dialysis.

Conclusions: Lower PAPI was associated with a lower baseline eGFR, lower in-hospital eGFR slope, and higher risk of dialysis. API was not associated with any kidney outcomes.

Keywords: CKD; cardiovascular disease; heart failure; hemodialysis.

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Conflict of interest statement

Disclosure forms, as provided by each author, are available with the online version of the article at http://links.lww.com/KN9/A867.

Figures

None
Graphical abstract
Figure 1
Figure 1
Relationship between PAPI/API with baseline eGFR and in-hospital eGFR slope. Association between PAPI and API with baseline eGFR (A and B) and in-hospital eGFR slope (C and D): Restricted cubic splines for the relationship between PAPI/API and baseline eGFR/in-hospital eGFR slope adjusted for age, sex, ejection fraction, diabetes, home medication use (ACEI/ARB, MRA), inotrope use at the time of initial hemodynamic measurement, and baseline eGFR are displayed. Distribution of PAPI and API are shown in gray histogram boxes with percentage prevalence along the right-side y axis. The mean eGFR slope was calculated by a linear mixed model incorporating every eGFR data point (limited to one data point per day of hospitalization). eGFR slope displayed in ml/min per 1.73 m2 per week. (A) Relationship between PAPI and baseline eGFR. Lower PAPI was associated with a lower mean eGFR of 3.27 ml/min per 1.73 m2 per halving of PAPI, although this relationship was nonlinear (Plinear 0.042). B. Relationship between API and baseline eGFR. No significant trend for baseline eGFR was observed with API. (C) Relationship of PAPI with eGFR slope. Decreasing PAPI was significantly associated with a negative eGFR slope (per halving PAPI −0.78 ml/min per 1.73 m2 95% CI [−1.25 to −0.32], Pglobal = 0.004) without evidence of nonlinearity (P for nonlinearity = 0.221). (D) Relationship of API and eGFR slope. No association was seen between API and in-hospital eGFR slope (Pglobal = 0.739). ACEI/ARB, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker; API, aortic pulsatility index; CI, confidence interval; MRA, mineralocorticoid receptor antagonist; PAPI, pulmonary artery pulsatility index.
Figure 2
Figure 2
Kaplan–Meier curves of receipt of dialysis by quartile of PAPI and API. Lower PAPI was associated with an increased probability of needing dialysis, while there was no significant association of between API and receipt of dialysis. PA, pulmonary artery.
Figure 3
Figure 3
Association of PAPI and API and need for dialysis. Restricted cubic splines for the relationship between PAPI/API and need for dialysis are displayed. PAPI is significantly associated with need for dialysis (Pglobal = 0.008) without evidence of nonlinearity (Plinear = 0.132). No association was seen between API and need for dialysis (Pglobal = 0.441). Distribution of PAPI and API is shown in gray histogram boxes with percentage prevalence along the right-side y axis. The median PAPI at baseline was 2.0 (IQR, 1.4–3.2) and median API was 1.8 (IQR, 1.2–2.7). Models include adjustment for age, sex, ejection fraction, diabetes, home medication use (ACEI/ARB, MRA), inotrope use at the time of initial hemodynamic measurements, and eGFR. HR, hazard ratio; IQR, interquartile range.
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