Elevated blood urea nitrogen level as a predictor of mortality in patients admitted for decompensated heart failure.

BACKGROUND Hospitalization for decompensated heart failure is associated with high mortality after discharge. In heart failure, renal function involves both cardiovascular and hemodynamic properties. We studied the relation between renal dysfunction and mortality in patients admitted for decompensated heart failure. METHODS The prognostic importance of four measures of renal function-blood urea nitrogen, serum creatinine, blood urea nitrogen/creatinine ratio, and estimated creatinine clearance-was evaluated in 541 patients (mean [+/- SD] age, 63 +/- 14 years; 377 men [70%]) with a previous diagnosis of heart failure (96% with New York Heart Association class III or IV symptoms) who were admitted for clinical decompensation. RESULTS During a mean follow-up of 343 +/- 185 days, 177 patients (33%) died. In multivariable Cox regression models, the risk of all-cause mortality increased with each quartile of blood urea nitrogen, with an adjusted relative risk of 2.3 in patients in the upper compared with the lower quartiles (95% confidence interval [CI]: 1.3 to 4.1; P = 0.005). Creatinine and estimated creatinine clearance were not significant predictors of mortality after adjustment for other covariates. Blood urea nitrogen/creatinine ratio yielded similar prognostic information as blood urea nitrogen (adjusted relative risk = 2.3; 95% CI: 1.4 to 3.8; P = 0.0007 for patients in the upper compared with the lower quartiles). CONCLUSION Blood urea nitrogen is a simple clinical variable that provides useful prognostic information in patients admitted for decompensated heart failure. In this setting, elevated blood urea nitrogen levels probably reflect the cumulative effects of hemodynamic and neurohormonal alterations that result in renal hypoperfusion.

[1]  M. Lauer,et al.  The prognostic value of estimated creatinine clearance alongside functional capacity in ambulatory patients with chronic congestive heart failure. , 2002, Journal of the American College of Cardiology.

[2]  R. Cooper,et al.  Trends in hospitalization rates for heart failure in the United States, 1973-1986. Evidence for increasing population prevalence. , 1990, Archives of internal medicine.

[3]  J. Murray,et al.  Mesangial cell, glomerular and renal vascular responses to endothelin in the rat kidney. Elucidation of signal transduction pathways. , 1989, The Journal of clinical investigation.

[4]  J. Goldberger,et al.  Prognostic factors in acute pulmonary edema. , 1986, Archives of internal medicine.

[5]  W. Abraham,et al.  Hormones and hemodynamics in heart failure. , 1999, The New England journal of medicine.

[6]  T. LeJemtel,et al.  Intravenous nesiritide, a natriuretic peptide, in the treatment of decompensated congestive heart failure. Nesiritide Study Group. , 2000, The New England journal of medicine.

[7]  Cockcroft Dw,et al.  Prediction of Creatinine Clearance from Serum Creatinine , 1976 .

[8]  J. Fleming,et al.  The accuracy of creatinine clearance with and without urine collection as a measure of glomerular filtration rate. , 1991, Postgraduate medical journal.

[9]  R. Cody,et al.  Sodium and water balance in chronic congestive heart failure. , 1986, The Journal of clinical investigation.

[10]  B. Zarowitz,et al.  Predictability of creatinine clearance estimates in critically ill patients , 1993, Critical care medicine.

[11]  J. Tu,et al.  Prognosis and Determinants of Survival in Patients Newly Hospitalized for Heart Failure: A Population-Based Study , 2002 .

[12]  T. Masaki,et al.  A sensitive sandwich-enzyme immunoassay for human endothelin. , 1989, Journal of immunological methods.

[13]  M. Packer.  The neurohormonal hypothesis: a theory to explain the mechanism of disease progression in heart failure. , 1992, Journal of the American College of Cardiology.

[14]  B. Brenner,et al.  Relative contribution of vasopressin and angiotensin II to the altered renal microcirculatory dynamics in two-kidney Goldblatt hypertension. , 1983, Circulation research.

[15]  D. Fukai,et al.  Effects of a specific endothelin-converting enzyme inhibitor on cardiac, renal, and neurohumoral functions in congestive heart failure: comparison of effects with those of endothelin A receptor antagonism. , 1999, Circulation.

[16]  M. Rich,et al.  CONGESTIVE HEART FAILURE IN OLDER ADULTS * : Epidemiology, Pathophysiology, and Etiology of Congestive Heart Failure in Older Adults , 1997, Journal of the American Geriatrics Society.

[17]  T. LeJemtel,et al.  Effect of nesiritide (B-type natriuretic peptide) and dobutamine on ventricular arrhythmias in the treatment of patients with acutely decompensated congestive heart failure: the PRECEDENT study. , 2002, American heart journal.

[18]  R. Schrier,et al.  Sodium and water retention in heart failure: pathogenesis and treatment. , 1997, Kidney international. Supplement.

[19]  P. Varadarajan,et al.  Prognosis of congestive heart failure in patients with normal versus reduced ejection fractions: results from a cohort of 2,258 hospitalized patients. , 2003, Journal of cardiac failure.

[20]  S. Yusuf,et al.  Relation of neurohumoral activation to clinical variables and degree of ventricular dysfunction: a report from the Registry of Studies of Left Ventricular Dysfunction. SOLVD Investigators. , 1994, Journal of the American College of Cardiology.

[21]  J. Feinglass,et al.  Systolic function, readmission rates, and survival among consecutively hospitalized patients with congestive heart failure. , 1997, American heart journal.

[22]  A. Charlesworth,et al.  Renal function, neurohormonal activation, and survival in patients with chronic heart failure. , 2000, Circulation.

[23]  L. Goldman,et al.  Outcomes of acute exacerbation of severe congestive heart failure: quality of life, resource use, and survival. SUPPORT Investigators. The Study to Understand Prognosis and Preferences for Outcomes and Risks of Treatments. , 1998, Archives of internal medicine.

[24]  R. Califf,et al.  Short-term intravenous milrinone for acute exacerbation of chronic heart failure: a randomized controlled trial. , 2002, JAMA.

[25]  N. Hollenberg,et al.  Relation of the Renin‐Angiotensin-Aldosterone System to Clinical State in Congestive Heart Failure , 1981, Circulation.

[26]  S. Yusuf,et al.  Comparison of neuroendocrine activation in patients with left ventricular dysfunction with and without congestive heart failure. A substudy of the Studies of Left Ventricular Dysfunction (SOLVD). , 1990, Circulation.

[27]  M. Domanski,et al.  The prognostic implications of renal insufficiency in asymptomatic and symptomatic patients with left ventricular systolic dysfunction. , 2000, Journal of the American College of Cardiology.

[28]  C. O'connor,et al.  The problem of decompensated heart failure: nomenclature, classification, and risk stratification. , 2003, American heart journal.

[29]  Deeb N Salem,et al.  Level of kidney function as a risk factor for atherosclerotic cardiovascular outcomes in the community. , 2003, Journal of the American College of Cardiology.

[30]  J. Dossetor.  Creatininemia versus uremia. The relative significance of blood urea nitrogen and serum creatinine concentrations in azotemia. , 1966, Annals of internal medicine.

[31]  L Goldman,et al.  Correlates of early hospital readmission or death in patients with congestive heart failure. , 1997, The American journal of cardiology.

[32]  M. Hediger,et al.  Molecular cloning and characterization of the vasopressin-regulated urea transporter of rat kidney collecting ducts. , 1996, The Journal of clinical investigation.

[33]  R. Califf,et al.  Prognostic Implications of Abnormalities in Renal Function in Patients With Acute Coronary Syndromes , 2002, Circulation.

[34]  J. Croft,et al.  Hospitalization of patients with heart failure: National Hospital Discharge Survey, 1985 to 1995. , 1999, American heart journal.

[35]  B. Brenner,et al.  Endothelin: a potent renal and systemic vasoconstrictor peptide. , 1989, The American journal of physiology.

[36]  M. Redfield,et al.  Integrated cardiac, renal, and endocrine actions of endothelin. , 1989, The Journal of clinical investigation.

[37]  M. Costanzo,et al.  Prognosis determination in patients with advanced heart failure. , 1997, The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation.

[38]  Eric J. Eichhorn.  Prognosis determination in heart failure. , 2001, The American journal of medicine.

[39]  R. Swaminathan,et al.  Prediction of creatinine clearance from plasma creatinine: comparison of five formulae. , 1989, British journal of clinical pharmacology.

[40]  A. Ajayi.  Estimation of creatinine clearance from serum creatinine: utility of the cockroft and gault equation in Nigerian patients , 2004, European Journal of Clinical Pharmacology.

[41]  L. Bankir,et al.  Renal urea transporters. Direct and indirect regulation by vasopressin , 2000, Experimental physiology.

[42]  L. Horowitz,et al.  Prognosis in severe heart failure: relation to hemodynamic measurements and ventricular ectopic activity. , 1983, Journal of the American College of Cardiology.

[43]  J. Cohn,et al.  Acute vasoconstrictor response to intravenous furosemide in patients with chronic congestive heart failure. Activation of the neurohumoral axis. , 1985, Annals of internal medicine.

[44]  D. Kohan.  Endothelins in the normal and diseased kidney. , 1997, American journal of kidney diseases : the official journal of the National Kidney Foundation.

[45]  G. Matzke,et al.  Validity of creatinine clearance estimates in the assessment of renal function , 1990, Clinical pharmacology and therapeutics.