Key result
Worsening renal function during AHF treatment frequently reflects effective decongestion rather than irreversible kidney injury.
Why the study?
Serum creatinine-based definitions of AKI and worsening renal function during hospitalization for acute heart failure may inadequately reflect complex cardiorenal interactions.
In acute heart failure, transient creatinine increases during decongestion reflect cardiorenal disease severity rather than isolated kidney injury, emphasizing that complete decongestion remains the primary therapeutic goal.
Continue decongestion despite creatinine rises in acute HF; confirms these reflect cardiorenal severity rather than isolated kidney injury.
Background: Renal function deterioration during hospitalization for acute heart failure (AHF) is common and is traditionally classified as acute kidney injury (AKI) or worsening renal function (WRF) based on changes in serum creatinine (Cr). However, Cr-based definitions may inadequately reflect the complex cardiorenal interactions occurring in AHF. Purpose: This narrative review summarizes and compares definitions of AKI and WRF used in AHF, evaluates their prognostic significance, and explores whether renal function deterioration should be interpreted as a marker of cardiorenal disease severity rather than isolated kidney injury. Methods: A narrative review of randomized trials, observational studies, post hoc analyses, and meta-analyses was conducted, focusing on Cr-based and nephrology-derived AKI definitions (RIFLE, AKIN, KDIGO), timing and baseline selection, congestion status, and the role of biomarkers and imaging in clinical interpretation. Results: The most widely used definition of WRF is an absolute increase in serum Cr ≥ 0.3 mg/dL. Multiple studies demonstrate that such changes frequently occur during effective decongestion and are not independently associated with adverse outcomes in the absence of residual congestion. In contrast, persistent congestion, impaired diuretic response, reduced renal reserve, and advanced cardiorenal comorbidity consistently predict worse prognosis. Nephrology-derived AKI definitions identify higher-risk patients but incompletely account for the hemodynamic and therapeutic context of AHF. Conclusions: In AHF, AKI and WRF often act as markers of underlying cardiorenal disease severity rather than direct indicators of irreversible kidney injury. Interpretation of renal function deterioration should be contextual, integrating congestion status, perfusion, renal reserve, and dynamic response to therapy. Achieving effective and complete decongestion remains the primary therapeutic objective in AHF, even in the presence of transient Cr increases.
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Aletras et al. (2026) conducted a review in Acute Heart Failure. Renal function deterioration during acute heart failure treatment frequently reflects cardiorenal disease severity and effective decongestion rather than isolated, irreversible kidney injury.
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