Editorial
Heart and kidneys, poor travel companions from the start of heart failure
Corazón y riñón, malos compañeros de viaje desde el inicio de la insuficiencia cardiaca
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Conde Martel" "autores" => array:1 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Conde Martel" "email" => array:1 [ 0 => "alicia.conde@ulpgc.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario de Gran Canaria Dr. Negrín, Las Palmas, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Universidad de Las Palmas de Gran Canaria, Las Palmas, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Corazón y riñón, malos compañeros de viaje desde el inicio de la insuficiencia cardiaca" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Acute heart failure (HF) has a growing incidence and prevalence and constitutes an epidemic, with more than a million hospitalizations annually in Europe and the United States,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> constituting the leading cause of hospitalization for those older than 65 years.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Acute HF is a complex syndrome that can affect almost all organs, with renal dysfunction (one of the most significant comorbidities in patients with HF) having special relevance. The prevalence of renal dysfunction is very high, affecting 30–50% of patients with HF.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The heart and kidneys are closely related in HF, with a bidirectional interaction between the organs, such that dysfunction in one organ affects the others, both in acute and chronic conditions. The term “cardiorenal syndrome” has been coined to define the simultaneous dysfunction of heart and kidneys, with 5 distinct types depending on the direction in which the effect occurs and its acute or chronic presentation.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The presence of kidney disease in patients with HF also has a considerable negative impact on the prognosis, with lower survival the lower the glomerular filtration rate. A loss of glomerular filtration, as occurs in acute kidney failure and chronic kidney disease (CKD), independently predicts mortality and accelerates the progression of HF.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Moreover, acute HF can occur as a decompensation of chronic HF or as the presentation of HF (<span class="elsevierStyleItalic">de novo</span>). Some 20–30% of patients with acute HF debut with HF.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,6</span></a> These patients with <span class="elsevierStyleItalic">de novo</span> HF or who debut with HF have differential characteristics compared with those with chronic HF, with fewer comorbidities, greater ejection fraction and lower frequency of CKD.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6,7</span></a> Nevertheless, HF is a progressive disorder from its onset, and the risk of readmissions increases during the disease’s progression,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> with a progressive shortening of the time between episodes. The antecedent of previous admissions is a factor of a poor prognosis, which is obviously not present in patients with <span class="elsevierStyleItalic">de novo</span> HF. Determining the factors associated with poorer progression in these patients who debut with HF is important for conducting interventions, by performing a closer follow-up that prevents readmissions. Despite the progress in treating HF, readmissions are still common. A quarter of patients are readmitted 30–90 days after discharge, a period of maximum vulnerability (especially the first 30 days) during which the follow-up should be intensified.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">In this issue, Torralba-Morón et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> assessed the prognostic value of renal function at admission in a series of 600 patients with a first episode of HF. The authors observed that renal function at admission was related to longer hospital stays and increased mortality at 1 year. In this study, the percentage of patients with a previous diagnosis of CKD was low (12.5%); however, the percentage of patients with an estimated glomerular filtration rate (eGFR) at admission <60<span class="elsevierStyleHsp" style=""></span>mL/min/1.73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> was quite a bit higher (37.7%), which shows a high percentage of patients with acute renal function impairment. In the multivariate analysis, renal function at admission and not the antecedent of CKD was the factor associated with a poorer prognosis at 1 year. The low percentage of patients with a previous diagnosis of CKD and the low 1-year mortality of this cohort (12%) might have been involved in the loss of statistical significance observed in the univariate analysis.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Renal function impairment at admission in patients with acute HF is frequent (20–50% of patients).<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10–13</span></a> From the pathophysiological viewpoint, this functional impairment is the result of complex multifactorial processes that include hemodynamic factors (such as renal artery hypoperfusion and venous congestion) and nonhemodynamic factors (such as neurohormonal activation) and includes the renin-angiotensin system and the sympathetic nervous system.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Renal function impairment during hospitalization is a true challenge for managing these patients, hinders treatment and has prognostic implications. A broad meta-analysis that included 57 studies with CKD and 28 studies with acute renal function impairment showed that both conditions were associated with higher mortality (both in acute and chronic HF and in patients with reduced and preserved ejection fraction).<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">However, there is growing acknowledgement that the relationship between acute renal function impairment and the prognosis is more complex than originally thought. Not all renal function impairment is associated with poorer progression, such that if the increase in creatinine is the result of the start of treatment with angiotensin-converting enzyme inhibitors or angiotensin <span class="elsevierStyleSmallCaps">II</span> receptor blockers or if it occurs with improvement in the congestion, the impairment is not associated with a poorer prognosis.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Another aspect analyzed in the study by Torralba-Moron et al.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> are the factors related to poorer renal function at admission. The authors found that the presence of diabetes, hypertension and lower hemoglobin were predictors of a lower glomerular filtration. These same factors have been linked in the literature not only with acute renal dysfunction but also with the development of CKD and its progression.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> Although it would have been interesting to determine the progression of the renal function and its discharge condition, the fact that a single reading is independently related with the prognosis allows us to stratify patients with greater risk of readmission, for whom closer follow-up needs to be conducted. As indicated by Damman et al.,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> the identification of patients with a high risk of readmission or mortality should include a measurement of renal function, which is corroborated in patients who debut with HF.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The authors recognize the limitations of the study, such as the cohort’s age (which would have helped analyze a longer follow-up period), the presence of a significant percentage of patients in whom the left ventricular ejection fraction could not be determined and the lack of availability of natriuretic peptide readings and the possible risk of diagnostic error. Nevertheless, the study reveals the significant prognostic value of renal function at admission, regardless of the ejection fraction.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Lastly, despite the poor prognosis conferred by renal function impairment to patients with HF, there is a ray of hope with the incorporation of new drugs with nephroprotective effect into the therapeutic arsenal. In patients with diabetes, sodium-glucose cotransporter 2 inhibitors have been shown to reduce hospitalizations for HF and delay or prevent the development of renal dysfunction, a field in which there has been no contributions for more than a decade.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a></p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Conde Martel A. Corazón y riñón, malos compañeros de viaje desde el inicio de la insuficiencia cardiaca. Rev Clin Esp. 2020;220:569–570.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Lessons learned in acute heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Cheema" 1 => "A.P. Ambrosy" 2 => "R.M. Kaplan" 3 => "M. Senni" 4 => "G.C. Fonarow" 5 => "O. 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