Elsevier

Heart Failure Clinics

Volume 4, Issue 4, October 2008, Pages 387-399
Heart Failure Clinics

Epidemiology
Epidemiology of Chronic Kidney Disease in Heart Failure

https://doi.org/10.1016/j.hfc.2008.03.008Get rights and content

Heart failure is common and is associated with a poor prognosis. Chronic kidney disease is common in heart failure and shares many risk factors with heart failure, such as age, hypertension, diabetes, and coronary artery disease. Over half of all patients who have heart failure may have moderate-to-severe chronic kidney disease. The presence of chronic kidney disease is associated with increased morbidity and mortality, yet it is also associated with underuse of evidence-based heart failure therapy that may reduce morbidity and mortality. Understanding the epidemiology and outcomes of chronic kidney disease in heart failure is essential to ensure proper management of these patients.

Section snippets

Heart failure: a syndrome of comorbidities

Because over 80% of patients who have heart failure are aged 65 years and older, most of these patients sustain one or more comorbidities. Furthermore, because heart failure is a syndrome and not a disease, per se, there are often one or more underlying causes that lead to the development of heart failure. Some of the most common causes of heart failure are hypertension, coronary artery disease, diabetes, and chronic kidney disease (CKD), which are often present as comorbidities in heart

Case 1

An 86-year-old white woman with a history of hypertension and atrial fibrillation developed progressive dyspnea about 2 years ago. Recently, her dyspnea worsened. She could barely walk inside her home and often slept on a recliner to avoid orthopnea. She denied paroxysmal nocturnal dyspnea, cough, wheezing, or chest pain. She also reported right upper quadrant pain, nausea, loss of appetite, and severe leg swelling. She had no emergency room visits or hospitalizations due to dyspnea. Current

Relevance of epidemiology to patient care

Do these patients have CKD? Is it possible to establish the diagnosis of CKD in these patients based on the information provided herein? Serum creatinine levels in both of the patients were less than 1.5 mg/dL, a cutoff often used by many clinical laboratories as the upper limit of normal serum creatinine levels. What are the prognostic and therapeutic implications of CKD in patients with heart failure? How should heart failure patients with CKD be treated? How common is CKD in heart failure?

Diagnosis of chronic kidney disease in heart failure

According to the National Kidney Foundation Kidney Disease Outcomes Quality Initiative (K/DOQI) guideline (http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm), serum creatinine alone should not be used to make the diagnosis of CKD. Serum creatinine is not a sensitive marker of the glomerular filtration rate (GFR) [9]. A basic evaluation for CKD includes an estimate of GFR, urinalysis, and quantification of albuminuria [10]. An estimated GFR less than 60 mL/min/1.73 m2 body surface

Prognostic implications of chronic kidney disease in heart failure

The presence of CKD is associated with a poor prognosis in heart failure and can be used to risk stratify patients for targeted intervention [6], [18], [19], [20], [21], [22], [23], [24]. According to one study, the risk of death in heart failure may be more strongly associated with a decline in the GFR than with a decline in the left ventricular ejection fraction [22]. Among patients with chronic heart failure in the Candesartan in Heart Failure: Assessment of Reduction in Mortality and

Therapeutic implications of chronic kidney disease in heart failure

Two aspects must be considered in the therapeutic implications of CKD in heart failure: (1) the impact of the presence of CKD on the receipt of evidence-based therapy, and (2) the importance of the administration of such therapy to heart failure patients with CKD. ACE inhibitors and angiotensin receptor blockers have been shown to reduce mortality in patients with systolic heart failure [37]; however, these drugs are often underused in heart failure. One of the reasons for this underuse is the

Epidemiology of chronic kidney disease in the United States

Like heart failure, CKD is also common. According to a recent study based on the 1999 to 2004 National Health and Nutrition Examination Surveys (NHANES), an estimated 13% of the population aged 20 years and older or nearly 26 million Americans have CKD [48]. The prevalence of stage 1, 2, 3, and 4 CKD was 1.8% (3.5 million), 3.2% (6.3 million), 7.7% (15.2 million), and 0.35% (0.7 million) of the population, respectively. Participants in that study had a mean age of 46 years, 51% were women, and

Age and the epidemiology of chronic kidney disease

The importance of age as a risk factor for CKD is further highlighted by a recent study of the prevalence of CKD in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study [50]. REGARDS is a nationally representative, population-based cohort study of 20,667 participants aged 45 or more years. REGARDS has been designed to identify risk factors for excess stroke mortality among African Americans and those living in the southeastern United States. The goal of REGARDS is to

Chronic kidney disease: a global epidemic

A study of the prevalence of CKD using a primary care database in the United Kingdom reported an overall prevalence of 8.5% among the population aged 18 or more years, with women having a higher prevalence (10.6% versus 5.8% in men) [52]. In that study, 68% of the patients were excluded due to a lack of valid data on serum creatinine. Patients had a mean age of 58 years, and 56% were women. As expected, the prevalence of CKD increased with age from 0.01% in the age group from 18 to 24 years to

Epidemiology of chronic kidney disease in cardiovascular disease

Because CKD and cardiovascular disease share many risk factors, the prevalence of CKD is expected to be higher in patients with cardiovascular disease than in the general population. However, studies on the prevalence of CKD in patients with cardiovascular disease are not as well conducted as those in the general population. In the Cooperative Cardiovascular Project, an estimated 13% of patients had blood urea nitrogen greater than 40 mg/dL or serum creatinine greater than 2.5 mg/dL [58]. In a

Epidemiology of chronic kidney disease in heart failure

Unlike in the general population, the epidemiology of CKD in heart failure is not well studied. Patients with high serum creatinine levels have often been excluded from randomized clinical trials in heart failure [64]. Data on the prevalence of CKD in heart failure are best derived from large heart failure registries involving hospitalized patients with acute heart failure (Table 2).

A study of about 120,000 contemporary hospitalized patients with acute heart failure from the ADHERE registry

Risk factors for chronic kidney disease in heart failure

Prospective epidemiologic data on the risk factor of CKD in patients with heart failure are scarce, and most associations are derived from cross-sectional studies. Data from the Framingham Heart Study suggest that age, baseline GFR, body mass index, smoking, and diabetes are risk factors for new-onset CKD in the general population [78]. Cross-sectional data from the NHANES survey suggest that in the general population age, ethnicity, education, diabetes, hypertension, cardiovascular disease,

Chronic kidney disease as a risk factor for heart failure

Because heart failure and CKD share common risk factors that often coexist, it may be difficult to determine whether CKD in heart failure is a case of prevalent or incident CKD, or a manifestation of cardiorenal syndrome [81], [82], [83], [84]. Data from the Cardiovascular Health Study indicate that, among older adults, increasing baseline serum creatinine levels are associated with a graded increase in the risk for incident heart failure [7], [85]. A further analysis of the Cardiovascular

Summary

Heart failure is common and is associated with a poor prognosis. Heart failure and CKD share many common risk factors and often coexist. About one third of trial-eligible patients with chronic heart failure and about two thirds of real-life hospitalized patients with acute heart failure are estimated to have CKD, defined as an MDRD-estimated GFR of less than 60 mL/min/1.73 m2 of BSA. CKD is associated with increased morbidity and mortality in heart failure. CKD is also associated with underuse

References (85)

  • A. Levin et al.

    Left ventricular mass index increase in early renal disease: impact of decline in hemoglobin

    Am J Kidney Dis

    (1999)
  • A. Al-Ahmad et al.

    Reduced kidney function and anemia as risk factors for mortality in patients with left ventricular dysfunction

    J Am Coll Cardiol

    (2001)
  • D.S. Silverberg et al.

    The use of subcutaneous erythropoietin and intravenous iron for the treatment of the anemia of severe, resistant congestive heart failure improves cardiac and renal function and functional cardiac class, and markedly reduces hospitalizations

    J Am Coll Cardiol

    (2000)
  • A. Levin et al.

    Canadian randomized trial of hemoglobin maintenance to prevent or delay left ventricular mass growth in patients with CKD

    Am J Kidney Dis

    (2005)
  • A. Levin et al.

    Prevalence of abnormal serum vitamin D, PTH, calcium, and phosphorus in patients with chronic kidney disease: results of the study to evaluate early kidney disease

    Kidney Int

    (2007)
  • D. Russo et al.

    Coronary artery calcification in patients with CRF not undergoing dialysis

    Am J Kidney Dis

    (2004)
  • P.M. Rothwell

    Treating individuals 2. Subgroup analysis in randomised controlled trials: importance, indications, and interpretation

    Lancet

    (2005)
  • A. Ahmed et al.

    Effects of angiotensin-converting enzyme inhibitors in systolic heart failure patients with chronic kidney disease: a propensity score analysis

    J Card Fail

    (2006)
  • A.K. Berger et al.

    Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in patients with congestive heart failure and chronic kidney disease

    Am Heart J

    (2007)
  • P.E. Stevens et al.

    Chronic kidney disease management in the United Kingdom: NEOERICA project results

    Kidney Int

    (2007)
  • H.M. Krumholz et al.

    Predicting one-year mortality among elderly survivors of hospitalization for an acute myocardial infarction: results from the Cooperative Cardiovascular Project

    J Am Coll Cardiol

    (2001)
  • D. Charytan et al.

    The exclusion of patients with chronic kidney disease from clinical trials in coronary artery disease

    Kidney Int

    (2006)
  • F.A. Masoudi et al.

    Most hospitalized older persons do not meet the enrollment criteria for clinical trials in heart failure

    Am Heart J

    (2003)
  • M.A. Pfeffer et al.

    Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall programme

    Lancet

    (2003)
  • K. Bibbins-Domingo et al.

    Renal insufficiency as an independent predictor of mortality among women with heart failure

    J Am Coll Cardiol

    (2004)
  • L.F. Fried et al.

    Renal insufficiency as a predictor of cardiovascular outcomes and mortality in elderly individuals

    J Am Coll Cardiol

    (2003)
  • W. Rosamond et al.

    Heart disease and stroke statistics–2007 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee

    Circulation

    (2007)
  • National Heart, Lung and Blood Institute, National Institutes of Health. Congestive heart failure in the United States:...
  • M.M. Redfield

    Heart failure–an epidemic of uncertain proportions

    N Engl J Med

    (2002)
  • L.A. Stevens et al.

    Assessing kidney function: measured and estimated glomerular filtration rate

    N Engl J Med

    (2006)
  • The National Kidney Foundation

    K/DOQI clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification

    Am J Kidney Dis

    (2002)
  • L.A. Stevens et al.

    Evaluation of the modification of diet in renal disease study equation in a large diverse population

    J Am Soc Nephrol

    (2007)
  • M.G. Shlipak et al.

    Cystatin C and prognosis for cardiovascular and kidney outcomes in elderly persons without chronic kidney disease

    Ann Intern Med

    (2006)
  • E. Randers et al.

    Serum cystatin C as an endogenous parameter of the renal function in patients with normal to moderately impaired kidney function

    Clin Nephrol

    (2000)
  • R. Hojs et al.

    Serum cystatin C as an endogenous marker of renal function in patients with mild to moderate impairment of kidney function

    Nephrol Dial Transplant

    (2006)
  • T.I. Justesen et al.

    Albumin-to-creatinine ratio in random urine samples might replace 24-h urine collections in screening for micro- and macroalbuminuria in pregnant woman with type 1 diabetes

    Diabetes Care

    (2006)
  • M.R. Cowie et al.

    Prevalence and impact of worsening renal function in patients hospitalized with decompensated heart failure: results of the prospective outcomes study in heart failure (POSH)

    Eur Heart J

    (2006)
  • H.L. Hillege et al.

    Renal function, neurohormonal activation, and survival in patients with chronic heart failure

    Circulation

    (2000)
  • H.L. Hillege et al.

    Renal function as a predictor of outcome in a broad spectrum of patients with heart failure

    Circulation

    (2006)
  • A.S. Go et al.

    Hemoglobin level, chronic kidney disease, and the risks of death and hospitalization in adults with chronic heart failure: the Anemia in Chronic Heart Failure Outcomes and Resource Utilization (ANCHOR) Study

    Circulation

    (2006)
  • Campbell RC, Sui X, Filippatos G, et al. Association of chronic kidney disease and outcomes in chronic heart failure: a...
  • W.M. McClellan et al.

    Anemia and renal insufficiency are independent risk factors for death among patients with congestive heart failure admitted to community hospitals: a population-based study

    J Am Soc Nephrol

    (2002)
  • Cited by (0)

    Dr. Ahmed is supported by the National Institutes of Health through grants from the National Heart, Lung, and Blood Institute (5-R01-HL085561-02 and P50-HL077100), and a generous gift from Ms. Jean B. Morris of Birmingham, Alabama. Dr. Campbell is supported by the National Institutes of Health through a grant from the National Institute of Diabetes and Digestive and Kidney Diseases (1-K23-DK-64649-1A2) and by the National Kidney Foundation Young Investigator Program.

    View full text