Trajectories in renal perfusion pressure during hemodynamically guided therapy are associated with worsening renal function and patient outcomes

Background Worsening renal function (WRF) during acute decompensated heart failure (ADHF) therapy portends worse outcomes. We hypothesized that renal perfusion pressure (RPP), systemic mean arterial pressure minus central venous pressure (CVP), is associated with and may elucidate mechanisms of WRF. We theorized that machine learning-based RPP trajectories could impact outcomes. Methods Patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization (PAC) Effectiveness (ESCAPE) Trial randomized to PAC-guided therapy were evaluated. M-estimation, logistic regression, and receiver operating characteristic analysis were performed. Trajectories were analyzed by selecting summary measures capturing the most variance in the trajectories using factor analysis and applying clustering with the k-means methods based on these summary measures. Results Among 143 patients (age 56.7 ± 13.8 years, 26.6 % female), 17 patients (11.9 %) had >30 % decrease in glomerular filtration rate (GFR) during therapy. Percent change in GFR (%∆GFR) was positively associated with percent change in RPP (%∆RPP) (M-estimation coefficient 0.248; p = 0.02). %∆GFR was associated with %∆RPP, controlling for body mass index and ischemic cardiomyopathy (M-estimation coefficients 0.22, −0.007, and − 0.109; p = 0.033). RPP trajectories were associated with overall survival [OS; Kaplan-Meier (KM) p < 0.001] and survival free of transplant, left ventricular assist device, and heart failure hospitalization (HFH, KM p = 0.002). Favorable RPP trajectory was associated with improved outcomes, even with elevated creatinine (OS: KM p < 0.001, HFH: KM p < 0.001). Mediation effect of CVP at discharge was 10.4 % and 10 % for baseline creatinine. Conclusions RPP changes potentially explain a mechanism of WRF in patients undergoing PAC-guided therapy for ADHF. Trajectories of RPP predict survival and hospitalization outcomes and could improve nuanced risk stratification of cardiorenal syndromes in patients with ADHF.