Prognostic Impact of Changes in Intrarenal Venous Flow Pattern in Patients With Heart Failure

https://doi.org/10.1016/j.cardfail.2020.06.016Get rights and content

Highlights

  • An intrarenal venous flow (IRVF) pattern could be changed depending on the status of heart failure over the clinical course.

  • A persistent discontinuous IRVF pattern was associated with progression of renal impairment.

  • A discontinuous IRVF pattern during follow-up correlated strongly with clinical outcomes independent of IRVF pattern at baseline.

  • Longitudinal change in intrarenal hemodynamics had prognostic impact in patients with HF.

Abstract

Background

It remains unclear whether intrarenal venous flow (IRVF) patterns in patients with heart failure (HF) could change over the clinical course, and whether the changes could have a clinical impact. Thus, this study aimed to clarify these characteristics as well as to identify the relation between changes in the IRVF pattern and renal impairment progression.

Methods and Results

Patients with HF with repetitive IRVF evaluations were enrolled. Doppler waveforms of IRVF were classified into the following 3 flow patterns: continuous, biphasic discontinuous, and monophasic discontinuous. Primary end points included death from cardiovascular diseases and unplanned hospitalization for HF. Finally, 108 patients with adequate images were enrolled. The IRVF in 35 patients (32.4%) shifted to another pattern at the follow-up examinations. The median brain natriuretic peptide level in the continuous flow pattern at follow-up was significantly decreased (183 to 60 pg/mL, P < .001), whereas that of the discontinuous flow pattern at follow-up was increased (from 339 to 366 pg/mL, P = .042) and the estimated glomerular filtration rate was decreased (from 55 to 50 mL/min/1.73 m2, P = .013). A multivariable Cox proportional hazard model analysis revealed that the discontinuous pattern at follow-up (P < .001) and brain natriuretic peptide (P = .021) were significantly associated with the end points, independent of age, estimated glomerular filtration rate, and serum sodium level.

Conclusions

The IRVF pattern could be changed depending on the status of congestion. Persistent or worsened renal congestion, represented by discontinuous flow patterns, during the clinical courses indicated a poor prognosis accompanied by renal impairment in patients with HF.

Section snippets

Study Population and Protocol

Patients with HF who underwent repetitive echocardiographic examinations with IRD assessments at the University of Tsukuba Hospital from 2013 to 2017 were enrolled retrospectively. The observation period continued until August 2019. The diagnosis of HF was made according to the Framingham criteria.9 Patients were excluded if they were <20 years of age or undergoing renal replacement therapy.

IRD assessments were performed at the discretion of the patient's providers to assess the congestion

Baseline Characteristics and Longitudinal Changes in IRVF

During the study period, 293 patients underwent ≥1 IRD assessment. Among them, 110 (110/293, 37.5%) with HF and repetitive IRD assessment were registered in this study, of whom 2 were excluded because of inadequate IRD images. Finally, the analysis included 108 patients. The patients were initially classified into the continuous (n = 33, 30.6%) and discontinuous (n = 75, 69.4%) groups according to their IRVF pattern at baseline. The latter consisted of patients with a biphasic discontinuous

Discussion

In this study, we demonstrated 3 major findings. First, the IRVF pattern could change depending on the HF status over the clinical course. Second, a persistent discontinuous IRVF pattern was associated with progression of renal impairment. Third, a discontinuous IRVF pattern during follow-up correlated strongly with clinical outcomes, independent of IRVF pattern at baseline. These results suggested that a longitudinal change in intrarenal hemodynamics had a prognostic impact in patients with HF.

Conclusions

The IRVF patterns changed depending on the status of HF. Persistent or worsened renal congestion, represented by discontinuous flow patterns during the clinical courses, indicated a poor prognosis accompanied by renal impairment in patients with HF. The findings suggest that the IRVF by the intrarenal Doppler method may be a feasible, noninvasive biomarker for stratifying vulnerable patients with HF in clinical settings. Further studies are needed to establish the evidence.

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