Worsening Renal Function Is Common and Associated With Higher Mortality in Cardiogenic Shock: A Cardiogenic Shock Working Group Report.

Background: Outcomes associated with worsening renal function (WRF) in cardiogenic shock (CS) remain poorly understood.

Objectives: To study the incidence of WRF in heart failure-CS (HF-CS) and acute myocardial infarction CS (AMI-CS), examine its association with in-hospital mortality (IHM), define the trajectory of renal function in CS, and identify independent predictors of WRF in HF-CS versus AMI-CS.

Methods: Patients in the Cardiogenic Shock Working Group registry (CSWG) from 2021-2024 were analyzed; those with baseline end-stage renal disease were excluded. WRF was defined as an increase in creatinine ≥0.3 mg/dl, a decrease in eGFR >25%, or initiation of renal replacement therapy (RRT) within 72 hours of CS diagnosis.

Results: Of 6269 CS patients, 35% developed WRF, including 32% of HF-CS and 41% of AMI-CS patients. Patients who developed WRF were more likely to be transferred from other hospitals (63% vs 50%, p<0.001). Baseline right atrial pressure (RAP) was higher in both HF-CS (15 mmHg vs 12 mmHg, p<0.001) and AMI-CS (13 mmHg vs 11 mmHg, p=0.02) patients with WRF compared to patients without WRF. Incidence of WRF was higher among patients exposed to both tMCS and vasoactive agents as compared to vasoactive drugs alone (46% vs. 29%, p<0.001). Overall rate of RRT initiation was 20% throughout admission with higher rates in patients with acute on chronic versus de novo HF-CS and in patients with STEMI-CS versus NSTEMI-CS in the first 24 hours. IHM was higher in patients with WRF (41% vs 21%, p<0.001). In patients with WRF, median eGFR declined steadily throughout the first 72 hours after CS diagnosis. Key independent predictors of WRF included RAP, lactate, transfer status, in patients with HF-CS and CKD, lactate and transfer status in patients with AMI-CS.

Conclusion: WRF is common and deleterious in both HF- and AMI-CS. Given the early association with worse outcomes, WRF may not only be prognostic but also represent a potential therapeutic target in future CS studies.