Kidney Function and Outcomes in Patients Hospitalized With Heart Failure

Ravi B. Patel, MD, MSC; Gregg C. Fonarow, MD; Stephen J. Greene, MD; Shuaiqi Zhang, MS; Brooke Alhanti, PHD; Adam D. DeVore, MD, MHS; Javed Butler, MD, MPH, MBA; Paul A. Heidenreich, MD; Joanna C. Huang, PHARMD; Michelle M. Kittleson, MD, PHD; Karen E. Joynt Maddox, MD, MPH; James J. McDermott, PHD; Anjali Tiku Owens, MD; Pamela N. Peterson, MD, MSPH; Scott D. Solomon, MD; Orly Vardeny, PHARMD, MS; Clyde W. Yancy, MD MSC; Muthiah Vaduganathan, MD, MPH


J Am Coll Cardiol. 2021;78(4):330-343. 

In This Article

Abstract and Introduction


Background: Few contemporary data exist evaluating care patterns and outcomes in heart failure (HF) across the spectrum of kidney function.

Objectives: This study sought to characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction.

Methods: Guideline-directed medical therapies were evaluated among patients hospitalized with HF at 418 sites in the GWTG-HF (Get With The Guidelines–Heart Failure) registry from 2014 to 2019 by discharge CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)-derived estimated glomerular filtration rate (eGFR). We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality.

Results: Among 365,494 hospitalizations (age 72 ± 15 years, left ventricular ejection fraction [EF]: 43 ± 17%), median discharge eGFR was 51 ml/min/1.73 m2 (interquartile range: 34 to 72 ml/min/1.73 m2), 234,332 (64%) had eGFR <60 ml/min/1.73 m2, and 18,869 (5%) were on dialysis. eGFR distribution remained stable from 2014 to 2019. Among 157,439 patients with HF with reduced EF (≤40%), discharge guideline-directed medical therapies, including beta-blockers, were lowest in discharge eGFR <30 mL/min/1.73 m2 or dialysis (p < 0.001). "Triple therapy" with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor–neprilysin inhibitor + beta-blocker + mineralocorticoid receptor antagonist was used in 38%, 33%, 25%, 15%, 5%, and 3% for eGFR ≥90, 60 to 89, 45 to 59, 30 to 44, <30 ml/min/1.73 m2, and dialysis, respectively; p < 0.001. Mortality was higher in a graded fashion at lower admission eGFR groups (1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2%, respectively; p < 0.001). Steep covariate-adjusted associations between admission eGFR and mortality were observed across EF subgroups, but was slightly stronger for HF with reduced EF compared with HF with mid-range or preserved EF (pinteraction = 0.045).

Conclusions: Despite facing elevated risks of mortality, patients with comorbid HF with reduced EF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.


Despite contemporary advances in care, hospitalization for heart failure (HF) remains a frequent, costly, and highly morbid event, carrying a subsequent 5-year mortality of >75% across the syndrome's spectrum of ejection fraction (EF).[1–3] Although several medical therapies have been demonstrated to reduce worsening HF events and mortality among individuals with heart failure with reduced ejection fraction (HFrEF), recent data suggest that implementation and titration of such therapies are suboptimal.[4,5]

Kidney dysfunction frequently coexists with chronic HF, and the presence of both is associated with worse clinical outcomes than either condition alone.[6–9] Whereas several contemporary classes of therapies for HFrEF (angiotensin receptor blockers [ARBs], angiotensin-converting enzyme [ACE] inhibitors, and mineralocorticoid receptor antagonists [MRAs]) have demonstrated clinical benefits among select individuals with chronic kidney disease (CKD),[10–12] historical data have suggested these therapies are infrequently used in this high-risk cohort[13–15] and contemporary data are lacking. As such, we evaluated clinical profiles, discharge medical therapies, and in-hospital mortality among patients hospitalized for HF across the spectrum of kidney function in the GWTG-HF (Get With The Guidelines–Heart Failure) registry.