Presence of Kidney Disease as an Outcome Predictor in Patients with Pulmonary Arterial Hypertension

Abstract

Background: Pulmonary arterial hypertension (PAH) may lead to right heart failure and subsequently alter glomerular filtration rates (GFR). Chronic kidney disease (CKD, GFR <60 mL/min/1.73 m²) may also adversely affect PAH prognosis. This study aimed to assess how right heart hemodynamics was associated with reduced estimated GFR (eGFR) and the association of CKD with survival in PAH patients. Methods: In a prospective PAH cohort (2003–2012), invasive hemodynamics and eGFR were collected at diagnosis (179 patients) and during follow-up (159 patients). The prevalence of CKD was assessed at PAH diagnosis. Variables, including hemodynamics, associated with reduced eGFR at diagnosis and during follow-up were tested in multivariate analysis. The association of CKD with survival was evaluated using a multivariate Cox regression model. Results: At diagnosis, mean age was 60.4 ± 16.5 years, mean pulmonary arterial pressure was 43 ± 12 mm Hg, and eGFR was 74.4 ± 26.4 mL/min/1.73 m². CKD was observed in 52 incident patients (29%). Independent determinants of reduced eGFR at diagnosis were age, systemic hypertension, and decreased cardiac index. Independent determinants of reduced eGFR during follow-up were age, female gender, PAH etiology, systemic hypertension, decreased cardiac index, and increased right atrial pressure. Age ≥60 years, female gender, NYHA 4, and CKD at diagnosis were independently associated with decreased survival. The adjusted hazards ratio for death associated with CKD was 1.81 (95% confidence interval [1.01–3.25]). Conclusion: CKD is frequent at PAH diagnosis and is independently associated with increased mortality. Right heart failure may induce renal hypoperfusion and congestion, and is associated with eGFR decrease.

Renal protective effect of sodium ferulate on pulmonary hypertension patients undergoing computed tomography pulmonary angiography

“…[12] Right heart failure known as venous congestion may induce renal hypoperfusion and congestion, and has been reported to be the major underlying cause for renal dysfunction. [13] However, such renal injury is mostly reversible, which highlight the necessity of individualized risk-benefit strategy.…”

Hot topics in the mechanisms of pulmonary arterial hypertension disease: cancer‐like pathobiology, the role of the adventitia, systemic involvement, and right ventricular failure

“…For short: the sick lung vessels affect the heart and the kidneys and are responsible for a muscle microvasculopathy. 125,137–139…”

Pulmonary Arterial Hypertension and the Kidney: Getting to the Heart of the Matter

“…So, while previous studies on predominant left-sided HF and volume overload point to high pressures on the right side as playing an important role in the development of impairment in renal function, interestingly the study by Bitker et al [5] on patients with PAH emphasizes the key role of the left cardiac dysfunction. These observations highlight the intertwined bi-directional pathways linking the 2 sides of the circulation, and underscore the clinical relevance of renal perfusion pressure (as defined by the difference between mean arterial pressure and central venous pressure) for prediction of renal function in this setting.…”

“…In this issue of the journal, Bitker et al [5] present the results of an observational study on 179 patients with PAH exploring the factors associated with renal dysfunction. The study population had a cardiac index of 2.6 L/ min/m 2 and an estimated GFR of 74.4 mL/min/1.73 m 2 at baseline; 29% of the patients had a GFR of less than 60 mL/min/1.73 m 2 at the time of the diagnosis of PAH.…”

“…The study by Bitker et al [5] did not explore the neurohormonal system or the markers of inflammation and endothelial activation. It has been proposed that venous congestion and increased venous pressures could change the endothelium from a quiescent redox profile to an activated proinflammatory, pro-oxidant, and pro-vasoconstrictive state.…”