Chronic kidney disease (CKD) is common and is associated with increased mortality
in heart failure (HF). However, it is unknown whether the effect of CKD on mortality
varies by left ventricular ejection fraction (LVEF). We evaluated the effect of CKD
on mortality in patients with systolic (LVEF ≤45%) and diastolic (LVEF >45%) HF. Of
the 7,788 patients in the Digitalis Investigation Group trial, 3,527 (45%) had CKD
(estimated glomerular filtration rate <60 ml/min/1.73 m2). We calculated the propensity score for CKD for each patient, using a multivariate
logistic regression model (c statistic 0.76, postmatch absolute standardized differences
<5% for all 32 co-variates). We matched 2,399 pairs of patients with and without CKD
with similar propensity scores. There were 757 (rate 1,049/10,000 person-years) and
882 (rate 1,282/10,000 person-years) deaths, respectively, in patients without and
with CKD (hazard ratio 1.22, 95% confidence interval 1.09 to 1.36, p <0.0001). CKD-associated
mortality was higher in those with diastolic HF (371 extra deaths/10,000 person-years,
hazard ratio 1.71, 95% confidence interval 1.21 to 2.41, p = 0.002) than in systolic
HF (214 extra deaths/10,000 person-years, hazard ratio 1.19, 95% confidence interval
1.07 to 1.32, p = 0.001), which was significant (adjusted p for interaction = 0.034).
A graded association was found between CKD-related deaths and LVEF. The hazard ratios
for CKD-associated mortality for the LVEF subgroups of <35%, 35% to 55%, and >55%
were 1.15 (95% confidence interval 1.02 to 1.29), 1.35 (95% confidence interval 1.11
to 1.64), and 2.33 (95% confidence interval 1.34 to 4.06). In conclusion, CKD-associated
mortality was higher in those with diastolic than systolic HF. Patients with diastolic
HF should be evaluated for CKD, and the role of inhibitors of the renin-angiotensin
system in these patients needs to be investigated.
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Article info
Publication history
Published online: December 11, 2006
Accepted:
August 23,
2006
Received in revised form:
August 23,
2006
Received:
June 22,
2006
Identification
Copyright
© 2007 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
