| BackgroundHeart disease and kidney damage are common clinical diseases, both of which are often cause and effect, namely cardiorenal syndrome (CRS). It has been classified by the7th Acute Dialysis Quality Initiative (ADQI) meeting consensus in2008, and CRS type I is a common and significant subtype of cardiorenal syndrome, which is acute kidney injury (AKI) secondary to acute cardiac insufficiency means[acute heart failure (AHF) and (or) acute coronary syndrome]. Due to heart-kidney interactions, recent mortality of patients with CRS type I was significantly higher in patients with heart or kidney damage alone. Recent studies have been found that AKI secondary to heart disease may also make long-term heart disease, chronic kidney disease and mortality increased.It is common that CRS type I whose morbidity and mortality bring the society and medicine much burden. As reported, the incidence of AKI associated with acute decompensated heart failure (ADHF) and acute coronary syndrome patients is approximately24% to45% and9% to19%. Data from Acute Decompensated Heart Failure National Registry (ADHERE) through2005showed that21% had SCr concentrations greater than2.0mg/dL,30%had a history of renal insufficiency, and9%had creatinine concentrations greater than3.0mg/dL in105,000individuals admitted for ADHF. As another study reported,27%to40%of patients hospitalized for ADHF develop AKI as defined by an increase in SCr of0.3mg/dL or greater. Risk predictors for this complication include reduced baseline renal function, diabetes, and prior HF. These patients experience more complicated hospital courses, longer in patient stays, and higher mortality rates.Sofar the internationally recognized standard of AKI diagnostic criteria are Risk, Injury, Failure, Loss of kidney function, End-stage renal disease (RIFLE), Acute Kidney Injury Network (AKIN) and Kidney Disease Improving Global Outcomes (KDIGO) are three. Whether RIFLE is better than AKIN is unknown, KDIGO combines the advantages of RIFLE and AKIN criteria, but has not yet been widely used. Recent years in a number of studies on cardiorenal syndrome type I, differences in the definitions used for worsening renal failure (WRF), namely the definition of AKI, differences in the observed time-risk after hospitalization, heterogeneity of the selected populations and no clear definiton of AKI in CRS type I by ADQI consensus, it is difficult to summarize the epidemiological characteristics of patients with CRS type I. However, it is first time to discuss common independent risk factors for adult patients of South China with CRS type I and allows for more comprehensive interpretation of the epidemiological characteristics of CRS type I. A recent study has showed that, KDIGO is better than RIFLE and AKIN criteria on assessing the prognosis of patients with AKI after cardiac surgery, but it is not clear whether KDIGO is better in predicting the prognosis of CRS type I.It may delay the diagnosis and treatment of AKI that previou AKI diagnostic criteria only by serum creatinine (Scr) and urinary output can neither reflect the nature of kidney damage, sites of injury, nor the extent of damage, whose sensitivity and specificity appear to be defects. Finding more sensitive and specific biomarkers is currently a research hotspot. Previous studies suggest that proteinuria is related to acute kidney injury and death, but its ability to predict the occurrence of CRS type I and death is unclear. One study has showed that, the risk of AKI in patients with sepsis is significantly improved when proteinuria by dipsticks appear (P=0.001). If the test which is cheap and convenient is used in patients with acute heart failure, we can effectively predict AKI occurred in early interventions to reduce mortality and improve prognosis, reduce health care burden.Fart I Independent risk factors in common for cardiorenal syndrome type I by different criteriaObjectiveTo explore independent risk factors in common for cardiorenal syndrome (CRS) type I by RIFLE, AKIN and KDIGO criteria of acute kidney injury (AKI).MethodsData was retrospectively collected from patients with acute heart failure (AHF) in Guangdong General Hospital and the First Affiliated Hospital of Sun Yat-sen University between July2005and July2012. Patients were excluded if they met the following exclusion criteria:admission SCr level>3.5mg/dl, end-stage renal disease with dialysis, early death within48h after admission, malignant tumor, hospital stay <48h, lack of at least2SCr measurements during hospitalization, cardiac surgery or cardio-angiography and missing clinical data. The primary outcome was AKI defined as RIFLE, AKIN and KDIGO criteria. Baseline SCr was estimated from either the admission value (if this was within the normal range) or if available, from another value within3months, whichever was lowest. Logistic regression analysis was identified as independent risk factors in common for diagnosis of AKI by three criteria.ResultsAmong1058patients, more patients were diagnosed as AKI by KDIGO (52.8%) than RIFLE (37.4%) and AKIN (47.9%). Logistic regression indicates that coronary heart disease, albumin<30g/L(OR1.437,95%CI1.071～1.929), C reactive protein<29.9mg/L (OR2.328,95%CI1.770～3.062), uric acid>479umol/L (OR1.813,95%CI1.359～2.418), hemoglobin<110g/L (OR1.582,95%CI1.177～2.126), use of diuretics (OR1.499,95%CI1.026～2.191) and vasoactive agent (OR2.124,95%CI1.531～2.945) within48hours after admission were independent factors for cardiorenal syndrome type I by RIFLE; albumin<30g/L (AKIN:OR1.490,95%CI1.099～2.020;KDIGO:OR1.386,95%CI1.021～1.882), hemoglobin<110g/L(AKIN:OR1.963,95%CI1.445～2.666;KDIGO:OR1.889,95%CI1.388～2.572), C reactive protein<29.9mg/L (AKIN:OR2.252,95%CI1.694～2.993; KDIGO:OR2.681,95%CI1.388～2.572), estimate glomerular filtration rate<60ml/(min.1.73m2), uric acid>479umol/L (AKIN:OR3.317,95%CI2.338～4.706;KDIGO:OR2.853,95%CI2.100～3.875), use of diuretics (AKIN:OR3.200,95%CI2.362～4.336; KDIGO:OR1.556,95%CI1.089～2.223) and vasoactive agent (AKIN:OR1.907,95%CI1.388-2.619; KDIGO:OR2.040,95%CI1.496～2.782) within48hours after admission may be independent factors for cardiorenal sydrome type I by AKIN and KDIGO.ConclusionAlbumin<30g/L, hemoglobin<110g/L, C-reactive protein<29.9mg/L, uric acid>479umol/L, use of diuretics and vasoactive agent within48hours after admission were independent risk factors in common for cardiorenal syndrome type I by RIFLE, AKIN and KDIGO criteria. Correction of the risk factors may reduce the incidence of CRS type I and improve prognosis. Part II Predictive value of Kidney Disease Improving Global Outcomes criteria for prognosis of cardiorenal syndrome type IObjectiveTo evaluate the value of KDIGO criteria (kidney disease:improving global outcomes), RIFLE (risk, injury, failure, loss of kidney function, end-stage kidney disease) and AKIN (the acute kidney injury network) for short-term prognosis of cardiorenal syndrome type I.MethodsData was retrospectively collected from patients with acute heart failure in Guangdong General Hospital between July2005and July2012. Patients were excluded if they met the following exclusion criteria:admission SCr level>3.5mg/dl, hospital stay<48h or no SCr within48h after admission, malignant tumor, end-stage renal disease with dialysis, cardiac surgery or cardio-angiography. AKI was defined as RIFLE, AKIN and KDIGO criteria. The primary outcome was regarded as in-hospital mortality. Baseline SCr was estimated from either the admission value (if this was within the normal range) or if available, from another value within3months, whichever was lowest. Kaplan-Meier curve was used to evaluate in-hospital survival by three AKI criteria and AKI by KDIGO but not RIFLE or AKIN in patients with cardiorenal syndrome type I and Cox regression was used for multivariate analysis of in-hospital mortality.ResultsAmong732patients,154cases (21%) were diagnosed as AKI by KDIGO instead of RIFLE or AKIN. Incidence for the cardiorenal syndrome type I by KDIGO, RIFLE and AKIN were significantly different (54.7%vs.38.6%vs.50.1%, χ2=39.85, P<0.001). Kaplan-Meier curve showed that in-hospital survival rates of patients with AKI by KDIGO but not RIFLE or AKIN are lower than those without AKI(Log rank P=0.011). Cox regression indicated that after adjusted for age, sex, hemoglobin, serum albumin, C-reactive protein and use of diuretics and ACEI/ARB, three AKI diagnostic criteria of RIFLE, AKIN and KDIGO were independent risk factors for in-hospital mortality in patients with CRS type I [risk ratio (RR)2.45,1.58,2.30, respectively, P<0.05]. AKI by KDIGO but not RIFLE or AKIN was an independent risk factor of in-hospital mortality [RR2.23,95%Confidence Intervals (95%CI)1.23-4.04, P=0.008].ConclusionKDIGO criteria was superior to RIFLE and AKIN criteria on predicting in-hospital mortality of cardiorenal syndrome type I.Part Ⅲ Proteinuria:an independent risk factor for development of cardiorenal syndrome type I and in-hospital mortalityObjectiveProteinuria is an established risk factor for acute kidney injury (AKI), but the role of proteinuria for cardiorenal syndrome type I is still unclear. The aim of the study is to analyse the association between proteinuria and cardiorenal syndrome (CRS) type I and in-hospital mortality.MethodsWe studied all consecutive patients hospitalized with AHF from July2005to July2012in Guangdong General Hospital and the First Affiliated Hospital of Sun Yat-sen Univetsiry. Demographic and clinical data were collected retrospectively. Patients were excluded if they met the following exclusion criteria:admission SCr level>3.5mg/dl, end-stage renal disease with dialysis, early death within48h after admission, malignant tumor, hospital stay<48h, lack of at least2SCr measurements during hospitalization, cardiac surgery or cardio-angiography and missing clinical data. Urinary protein in the first48hours after admission were recorde and AKI was defined by KDIGO criteria. Baseline SCr was estimated from either the admission value (if this was within the normal range) or if available, from another value within3months, whichever was lowest. Proteinuria was defined as mild (trace to1+) or heavy (2+to4+) according to the results of the dipstick test. Logistic regression analysis was used to determine whether proteinuria is an independent risk factor for the occurrence of CRS type I and in-hospital mortality or not. In-hospital survival of patients with CRS type I along with proteinuria was assesed by Kaplan-Meier curves.Results1058patients were enrolled. The incidence of CRS type I with proteinuria was significantly higher than non-proteinuria group (67.9%vs.34.3%, P<0.001). Logistic regression analysis showed that after adjusted for age, sex, hypertension, diabetes, previous history of coronary heart disease, estimated glomerular filtration rate (eGFR), hemoglobin, serum albumin, uric acid, left ventricular ejection fraction (LVEF) during hospitalization, New York Heart Association functional class (NYHA), use of angiotensin converting enzyme inhibitors or angiotensin receptor antagonists (ACEI/ARB) and diuretics within48hours after admission, proteinuria was an independent risk factor for the development of CRS type I and in-hospital mortality (OR3.335,95%CI2.516-4.420; OR1.785,95%CI1.164-2.737). Mild and heavy proteinuria exhibited a stepwise increased ratio for both development of CRS type I (Mild proteinuria:OR2.801,95%CI2.076±3.778;Heavy proteinuria: OR5.607,95%CI3.583±8.775) and in-hospital mortality (Mild proteinuria: OR1.735,95%CI1.107～2.718; Heavy proteinuria:OR2.021,95%CI1.1693.496). Kaplan-Meier curve indicated that in-hospital survival of CRS type I patients with proteinuria were lower than CRS type I patients without proteinuria (Long rank p<0.001). ConclusionProteinuria is an independent risk factor for the development of CRS type I and in-hospital mortality, Attention should be paid for proteinuria in order to early prevention of CRS type I and improve the prognosis. |
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