Jacob Joseph1; Peter Guarino2; Zahi Rafeq3; James Kaufman4
1 VA Boston & Boston Univ， West Roxbury， MA
2 VA Connecticut Healthcare， West Haven， CT
3 Boston Univ， West Roxbury， MA
4 VA Boston & Boston Univ， West Roxbury， MA
Background: Subjects with renal dysfunction are routinely excluded from clinical trials of heart failure. Hence the impact of risk factors and medications on heart failure outcomes in patients with kidney disease is not well known.
Methods: The Homocysteinemia in Kidney and End Stage Renal Disease (HOST) trial examined the effect of the combination of high dose folic acid and vitamins B12 and B6 on all-cause mortality or the combined endpoint of myocardial infarction， stroke or lower-limb amputation. Over a median follow-up period of 3.2 years， there was no effect of vitamin treatment on outcomes (heart failure was not included as an endpoint). We collected data on heart failure admissions from all 2056 participants at baseline and during the study follow-up period. We analyzed the data to examine the association of demographic and treatment variables including vitamin treatment on the combined outcome of heart failure admission and all-cause mortality. Associations were examined separately in end stage renal disease (ESRD) and advanced chronic kidney disease (ACKD) by Cox proportional hazards regression.
Results: Vitamin treatment was not significantly associated with the outcome in either group. As shown in Table 1， age， history of diabetes and myocardial infarction were associated with increased risk of outcome in both ESRD and in ACKD. African-American race and history of hypertension were associated with decreased risk， and use of beta-blockade with increased risk in ESRD， while baseline history of heart failure and use of aldosterone inhibitors were associated with increased risk in ACKD. Hemoglobin level and use of angiotensin converting enzyme inhibitors (ACEI) were associated with decreased risk in ACKD.
Conclusions: Despite the possibility of adverse associations due to confounding by indication， the use of ACEI is associated with a decreased risk of heart failure admissions and all-cause mortality in subjects with ACKD， but not ESRD.
Factors Predicting Heart Failure Outcomes in Kidney Disease