Nohria A et al. (2008) Cardiorenal interactions: insights from the ESCAPE trial. J Am Coll Cardiol 51: 1268–1274

Deterioration of renal function in patients with heart failure can markedly worsen prognosis; however, the mechanisms underlying this relationship are unclear. To investigate the associations between renal dysfunction and cardiac hemodynamics, the ESCAPE trial investigators compared therapy guided by pulmonary artery catheterization (PAC) with treatment based on clinical assessment alone in 433 patients with advanced decompensated heart failure.

Patients were randomized on a 1:1 basis to one of the two treatment arms. The median serum creatinine (SCr) level at baseline was 132.6 µmol/l (1.5 mg/dl), and the median baseline estimated glomerular filtration rate (eGFR) was 71.4 ml/min. Baseline elevated SCr, baseline reduced eGFR, discharge elevated SCr and discharge reduced eGFR were all associated with significantly increased risks of death, and death or rehospitalization, at 6 months (P ≤0.002 for all); however, worsening renal function (defined as an increase in SCr of ≥26.52 µmol/l [0.3 mg/dl] or a decline in eGFR of ≥25%) was not. Among patients randomized to PAC, weak but significant correlations were noted between the baseline measurements of SCr and eGFR and right arterial pressure (r = 0.165, P = 0.03, and r = −0.195, P = 0.01, respectively). No other correlations were noted between baseline hemodynamic parameters and baseline renal insufficiency, and no correlations were observed between baseline hemodynamic measurements and worsening of renal function. Comparisons of patient outcome in the two treatment arms revealed that PAC-guided treatment did not reduce 30-day mortality, length of hospitalization, or risks of death or death or hospitalization at 6 months. Furthermore, PAC did not reduce the incidence of worsening renal function.

These results, say the authors, indicate that baseline renal dysfunction has a greater influence on prognosis than does deterioration of renal function during hospitalization.