Clinical profile and determinants of NECPAL positivity in advanced cardiorenal syndrome: a prospective multicentre study

Introduction Advanced cardiorenal disease (CRD) is characterized by a high burden of comorbidity and mortality, persistent symptoms, and frequent healthcare utilization. Identifying patients with unmet supportive care needs in multidisciplinary heart failure clinics remains challenging. The NECPAL (NECesidades PALiativas) tool was developed to detect patients with advanced chronic conditions who may benefit from a palliative care-oriented approach. Purpose To describe the clinical profile of NECPAL-positive patients with CRD and to identify factors independently associated with NECPAL positivity at first visit. Methods Prospective, multicentre observational study including consecutive patients with CRD followed in three tertiary cardiorenal clinics. NECPAL assessment was performed during routine baseline evaluation. Demographic data, comorbidities, laboratory parameters, frailty indices and healthcare resource utilization were recorded. Multivariable logistic regression analysis was performed to identify independent determinants of NECPAL positivity. Model discrimination was assessed using the area under the receiver operating characteristic curve (AUC). Results A total of 124 patients were included (mean age 73.4±9.6 years; 75.8% male). Forty-seven patients (37.9%) were NECPAL-positive (Figure 1). Compared with NECPAL-negative patients, NECPAL-positive patients were older (p<0.001), had more advanced chronic kidney disease (p=0.004), greater prevalence of asthenia (p=0.005), higher NYHA functional class (p<0.001), and higher NT-proBNP levels (p<0.001) (Figure 2A). Healthcare resource utilization in the previous year was greater among NECPAL-positive patients, with more emergency department visits (53.2% vs 24.7%, p=0.002) and hospital admissions (34.0% vs 15.6%, p=0.03). NECPAL-positive patients also presented with higher scores on the EQ-5D-5L (p=0.005), Barthel (p<0.001), PROFUND (p<0.001; Figure 2B), and Charlson (p=0.002) scales. No differences were observed in left ventricular ejection fraction or guideline-directed medical therapy. In multivariable analysis, older age (p=0.003), lower hemoglobin levels (p=0.035), hypertension (inverse association, p=0.012) and higher PROFUND score (p<0.001) were independently associated with NECPAL positivity. The model showed good discrimination (AUC 0.894) (Figure 2C). Conclusion In patients with advanced CRD, NECPAL positivity identifies a subgroup with greater frailty, higher comorbidity burden and increased healthcare utilization, independent of ventricular function and medical therapy. These findings support the clinical relevance of systematic NECPAL assessment in multidisciplinary cardiorenal clinics to trigger early supportive care.Figure 1.Basal characteristicsFigure 2.NECPAL validation