Prevalence and implications of heart failure stages A-D in patients with chronic kidney disease
Authors: Lauridsen A , Landler N E , Olsen F J , Johansen N D , Lassen M C H , Christensen J , Christoffersen C , Ballegaard E L F , Soerensen I M H , Bjergfelt S S , Bro S , Feldt-Rasmussen B , Hansen D , Biering-Soerensen T 
Published: November 2023

Abstract

Background
Heart failure (HF) is a frequent comorbidity among patients with chronic kidney disease (CKD). Echocardiography allows for simple, non-invasive evaluation of structural and functional heart disease that could potentially classify patients at high risk of HF.

Purpose
This study aimed to assess the prevalence of HF stages A-D defined by the AHA/ACC/HFSA in CKD patients, and to report the incidence rates of renal outcomes and mortality of these stages.

Methods
This is a prospective cohort study. Patients aged 30 to 75 years with estimated glomerular filtration rate (eGFR) stages G1 to G5 pre-dialysis were included. All participants were examined using a pre-defined echocardiographic protocol. HF stages B and C/D were defined based on ejection fraction, global longitudinal strain, TAPSE, left ventricular mass, left ventricular diameter, left atrial volume index, and valvular heart disease in accordance with the AHA/ACC/HFSA guidelines. The outcomes examined were (1) a composite of kidney transplantation and dialysis and (2) all-cause mortality.

Results
A total of 825 patients with CKD were included. Mean age was 58±13 years and 37% were female. The participants were categorized as follows: Stage A HF: 352 (42.7%); stage B HF: 295 (35.8%); and stage C/D HF: 122 (14.8%). In total, 56 participants did not fulfil the criteria of HF stage A, B, C, or D and were classified as HF stage 0. Figure 1 displays the prevalence of HF stages across CKD stages. Poorer eGFR (P for trend 0.001) and urine albumin/creatine ratio (P for trend 0.005) were both significantly associated with increasing HF stages in linear regression models (including age, sex, and systolic blood pressure). During a median follow-up of 4 years, 115 patients (13.9%) developed the composite renal outcome and 74 patients (9.0%) died. Incidence rate per 100 patient-years for the composite renal outcome according to HF-stages was 2.3 (95%CI: [0.95;5.5]) for stage 0, 3.3 (95%CI: [2.5;4.5]) for stage A, 3.8 (95%CI: [2.8;5.1]) for stage B, and 6.3 (95%CI: [4.3;9.3]) for stage C/D. The incidence rate did only significantly differ between stage C/D and stage 0 (p = 0.026), and HF stage C/D was the only stage associated with the composite renal outcome in univariable Cox regression (HR = 2.80 (95%CI: [1.07;7.31], p = 0.036)). Incidence rate of death (per 100 patient-years) by 0, A, B, and C/D HF-stages were 1.3 (95%CI: [0.43;4.2]), 1.0 (95%CI: [0.63;1.7]), 2.5 (95%CI: [1.7.;3.6]), and 7.3 (95%CI: [5.1;10]), respectively. Incidence of death was only significantly higher in stage C/D compared with stage 0 (p&lt;0.001). Also, stage C/D was the only stage that was significantly associated with all-cause mortality in univariable Cox regression (HR = 5.47 (95%CI: [1.67;17.9], p = 0.005)).

Conclusion
Among patients with CKD, worse HF stages became more prevalent with worsening kidney function, and both incidence rates of the composite renal outcome and of death were higher in HF stage C/D.HF stages distributed on CKD stages