Renal function and acute heart failure outcome | Medicina Clínica (English Edition)

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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Heart failure is a clinical syndrome whose prevalence reaches more than 10&#37; in people over 70 years of age in developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">1</span></a> In Spain&#44; AHF is the leading cause of hospitalization in adults over 65 years of age&#44; represents more than 100&#44;000 hospital admissions per year and is a turning point in the prognosis of heart failure&#44; with approximately a 30&#37; mortality rate within a year following a decompensation event&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Acute heart failure &#40;AHF&#41; affects other organs too&#44; therefore its approach is predominantly multidisciplinary&#44; involving different health system levels&#46;<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">3&#44;4</span></a> Despite efforts to find therapies that modify the natural evolution of AHF&#44; its prognosis has remained essentially unchanged during the last decades<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">5&#44;6</span></a> and the different clinical trials have failed to provide new drugs for its treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">7</span></a> For this reason&#44; Spain has recently developed different proposals to improve pre-hospitalization care&#44;<a class="elsevierStyleCrossRefs" href="#bib0340"><span class="elsevierStyleSup">8&#8211;10</span></a> to assess the fragility that patients often associate with AHF&#44;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">11&#44;12</span></a> to identify precipitating decompensation factors<a class="elsevierStyleCrossRefs" href="#bib0365"><span class="elsevierStyleSup">13&#44;14</span></a> or to improve decision-making regarding admission or discharge<a class="elsevierStyleCrossRefs" href="#bib0375"><span class="elsevierStyleSup">15&#8211;17</span></a>&#59; and specialized care circuits have been designed for the early stages of decompensation or follow-up after the initial treatment&#44;<a class="elsevierStyleCrossRefs" href="#bib0390"><span class="elsevierStyleSup">18&#44;19</span></a> all with the purpose of improving the prognosis of these patients&#46; In this sense&#44; and with the aim of helping decision-making in patients with AHF&#44; various variables and predictive models have been studied&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">20</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Renal function and its worsening has the most relevant association with a poor prognosis and its prevalence in heart failure is high&#44; as shown by the results of a meta-analysis in which 53&#37; of patients with AHF had chronic kidney disease &#40;CKD&#41; and whose coexistence was associated with higher mortality &#40;OR 2&#46;35&#44; 95&#37; CI&#58; 2&#46;25&#8211;2&#46;54&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">21</span></a> In the EAHFE registry&#44; with data on 5845 patients treated due to AHF in the Spanish hospital emergency services&#44; 22&#46;3&#37; had CKD&#44; defined as having a serum creatinine &#62;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and&#44; during the acute event&#44; an estimated glomerular filtration rate &#40;eGFR&#41; &#60;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> was observed in 57&#37; of patients&#44; an eGFR &#60;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> in 14&#37; of patients and an eGFR &#60;15<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> in 5&#37; of patients&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The pathophysiological relationship that is established between the heart and the kidney is complex&#46; The definition of cardiorenal syndrome&#44; initially classified into 5 categories and then extended to 7&#44; aims to clarify this complexity&#46; Within this cardiorenal syndrome classification&#44; cases of AHF with worsening renal function &#40;WRF&#41; are classified as type 1 or hemodynamic&#44;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">22</span></a> but the concept of WRF defined by the European Society of Cardiology continues to be used as an increase in serum creatinine &#8805;0&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl or 25&#37;&#44; or a decrease in eGFR of 20&#37;&#44; compared to baseline&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">1</span></a> It is also difficult to know how to assess renal function in patients with AHF&#44; essentially due to the variety of methods of doing so&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">23</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">With the aim of analysing published studies that investigate the relationship between different ways of assessing renal function and relating their abnormalities with prognosis in patients with AHF&#44; the following systematic review has been carried out&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Method of review and selection of articles</span><p id="par0030" class="elsevierStylePara elsevierViewall">A literature search was conducted between May 2016 and December 2017&#44; in the Pubmed and Web of Science databases&#46; The search criteria that were used are shown in <a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#46; We selected papers written in Spanish&#44; English&#44; French or German&#44; that had a summary and that evaluated the prognostic role of any renal function variable in AHF in non-selected samples of patients&#46; We discarded review articles&#44; communications to conferences&#44; clinical trials &#40;considering them selected samples&#41; and studies with specialized unit samples or less than 200 patients&#46; The cross references were checked to verify that the inclusion of any relevant work was not omitted from the papers selected&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">The review process identified 33 papers that met the inclusion criteria&#44; 29 coming directly from the search strategy and 4 from the cross-references review&#46; The authors agreed to limit the analysis to laboratory parameters&#44; and it was ruled out to analyze other variables that influenced the progression and prognosis of renal function&#44; such as&#44; for example&#44; loop diuretic therapy&#46; The variables analyzed in the different studies have been grouped according to the parameter considered and analyzed&#58; 1&#41; serum creatinine&#44; 2&#41; BUN or BUN&#47;creatinine ratio&#44; 3&#41; CKD&#44; 4&#41; formula for calculating eGFR&#44; 5&#41; acute kidney injury &#40;AKI&#41; and 6&#41; new markers of kidney damage&#46; Given that no meta-analysis was planned to aggregate the results of the different studies&#44; a homogeneous definition of these parameters was not required&#46; On the other hand&#44; the particularities referring to the definition of each parameter are discussed in the text corresponding to the discussion of each of them&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Serum creatinine</span><p id="par0040" class="elsevierStylePara elsevierViewall">Serum creatinine has been used for decades as a marker of kidney function&#46; It is a protein that comes from the skeletal muscles and is filtered almost exclusively in the glomerulus&#46; Given this origin&#44; there will be variations depending on age and sex&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the studies that analyze the prognostic significance of serum creatinine in AHF&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0045" class="elsevierStylePara elsevierViewall">WRF refers to a serum creatinine variation &#8805;0&#46;3 or 0&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; or the increase &#8805;25&#37; of creatinine&#44; but it is not a parameter for which there is a homogeneous definition&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">24</span></a> WRF is described as a variable in which various physiopathological mechanisms intervene&#44; such as neurohormonal activation&#44; decreased renal perfusion&#44; the presence of renal venous congestion&#44; the use of drugs with renal involvement and the presence of CKD&#44; and globally its presence is related to an increased risk of death or rehospitalization&#46; In a retrospective cohort study of 646 patients admitted for AHF&#44; the WRF during the first 7 days of admission was associated with higher mortality or readmission &#40;HR 1&#46;24&#44; 95&#37; CI&#58; 1&#46;06&#8211;1&#46;45&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0059&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">25</span></a> These results coincide with another study that analyzed data from an administrative base of 14&#44;017 patients admitted for AHF&#44; of which 5035 &#40;35&#46;9&#37;&#41; had an WRF during hospitalization &#40;42&#46;7&#37; persistent&#44; 37&#46;5&#37; persistent but of unknown duration and 19&#46;8&#37; transient&#41;&#46; Hospital re-admission at 30 days was higher in all groups with RR 1&#46;29 &#40;95&#37; CI&#58; 1&#46;17&#8211;1&#46;42&#41;&#59; RR 1&#46;12 &#40;95&#37; CI&#58; 1&#46;01&#8211;1&#46;26&#41; and RR 1&#46;14 &#40;95&#37; CI&#58; 1&#46;01&#8211;1&#46;31&#41;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">26</span></a> The ADHERE registry describes a 20&#46;3&#37; persistent WRF and 11&#46;7&#37; transient WRF&#44; with an HR of 1&#46;73 &#40;95&#37; CI&#58; 1&#46;57&#8211;1&#46;91&#41; and 1&#46;19 &#40;95&#37; CI&#58; 1&#46;05&#8211;1&#46;35&#41;&#44; respectively&#44; for mortality 90 days after discharge&#46; In this study&#44; the presence of previous CKD was related to more persistent WRF and mortality at 90 days&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">27</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">In the absence of congestion&#44; it is suggested that WRF could have no prognostic value and that it could be due to a diuretic or ACEI therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">28</span></a> On the other hand&#44; persistent congestion along with an WRF would be indicative of poor progression&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">29</span></a> On the other hand&#44; whether an improvement in renal function could have a prognostic significance has also been raised and similar conclusions have been reached&#46; Up to 31&#46;4&#37; of 903 patients hospitalized for AHF showed an improvement in renal function during hospitalization but showed a higher mortality with congestion and diuretic resistance &#40;HR 1&#46;3&#44; 95&#37; CI&#58; 1&#46;1&#8211;1&#46;7&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;011&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">30</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Urea nitrogen and urea nitrogen&#47;creatinine ratio</span><p id="par0055" class="elsevierStylePara elsevierViewall">Blood urea nitrogen &#40;BUN&#41; and creatinine are products of the metabolism of nitrogen compounds&#46; Its prognostic value has been described due to its association with the activation of the neurohormonal and the renin&#8211;angiotensin&#8211;aldosterone axis&#44; a phenomenon related to congestion that characterizes AHF&#46; In this context&#44; it has been suggested that there is an expansion of intravascular volume as a compensation mechanism&#44; so that the amount of urea excreted is disproportionately reduced compared to the glomerular filtration&#44; which results in a BUN&#47;creatinine ratio increase&#46; The results of the studies analyzed are shown in <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">When the 1-year mortality of a total of 610 patients with AHF was analyzed&#44; age and BUN were identified as the best independent predictors of mortality&#44; and 3 risk groups were created&#58; high risk &#40;BUN &#62;27&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and age &#62;86 years&#41;&#44; intermediate risk &#40;BUN &#62;27&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and age &#8804;86 years&#41; and low risk &#40;BUN &#8804;27&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#59; in the groups of more risk there were more cases with CKD&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">31</span></a> Baseline BUN increase is related to more in-hospital mortality and is interpreted as the expression of an intrinsically abnormal renal function or of a potentially reversible vasomotor nephropathy&#44; both of which are secondary to hemodynamic and neurohormonal abnormalities typical of AHF&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">32</span></a> The analysis of the ADHERE registry concludes that the eGFR and the BUN provide complementary information&#46; Both mortality and hospital stay were associated with the degree of renal dysfunction and the increase of BUN&#44; and the latter was the most potent predictor of in-hospital death&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">33</span></a> In the presence of AKI along with a high BUN&#47;creatinine ratio &#40;but not BUN or creatinine on their own&#41; there is an increased risk of mortality&#44; indicating that stratifying the risk of AKI is useful&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">34</span></a> In addition&#44; the existence of a high BUN&#47;creatinine ratio associated with a transient improved renal function during admission was associated with higher mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">35</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">In the presence of renal dysfunction&#44; BUN&#47;creatinine has also been proposed as a discriminating variable in relation to greater diuretic resistance and worse survival&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">36</span></a> One of the most important predictors for BUN increase is systolic blood pressure&#44; reason why it is suggested that caution should be exercised regarding a decrease in blood pressure&#46; On the other hand&#44; it seems that beta-blocker treatment could prevent the increase of BUN&#44; by blocking the sympathetic nervous system&#44; so its early initiation during AHF is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">37</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Chronic kidney disease</span><p id="par0070" class="elsevierStylePara elsevierViewall">Another aspect to consider is the time of onset of renal dysfunction&#44; that is&#44; evaluating whether the patient who has AHF decompensation already has established CKD&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows an already established CKD as a risk variable for AHF&#46; The Italian registry <span class="elsevierStyleItalic">IN-HF Outcome</span> studied the group of patients with CKD&#44; specifically with an eGFR &#60;40<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> and found that the predictors of in-hospital mortality in this group were&#58; altered level of consciousness&#44; advanced age&#44; hyponatremia&#44; systolic blood pressure and baseline eGFR&#46; In 1-year mortality&#44; the same predictors were maintained&#44; except eGFR&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">38</span></a> In this analysis&#44; the authors describe the paradox of diabetes&#44; in which the presence of its association with CKD was associated with a lower 1-year mortality&#46; However&#44; they acknowledge that it may be due to a selection bias or the size of the sample&#46; Miguel-Yanes et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">39</span></a> based on the analysis of the Spanish minimum basic data set&#44; corroborated that the established renal disease is associated with higher in-hospital mortality&#44; but there was no apparent relationship with the presence of diabetic nephropathy&#46; CKD and a worsening of it during an AHF admission are also related to worse prognosis&#44;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">40</span></a> as shown by the analysis of the ATTEND registry&#46; In-hospital mortality associated with renal dysfunction was similar in all groups but was independent of the presence of signs of renal congestion or hypoperfusion&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">41</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Formula for calculating the estimated glomerular filtration rate</span><p id="par0075" class="elsevierStylePara elsevierViewall">Renal function is defined from the calculation of eGFR&#44; which is estimated with the clearance of serum creatinine using different formulas&#44; mostly MDRD and CKD-EPI&#46;<a class="elsevierStyleCrossRef" href="#bib0510"><span class="elsevierStyleSup">42</span></a><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> shows 2 studies that have investigated which would be the most suitable formula to assess the prognosis&#46; The MDRD-4 and CKD-EPI formulas were evaluated from the RICA registry regarding patients admitted for AHF in Internal Medicine&#46; More patients with baseline renal dysfunction were identified with the CKD-EPI formula&#46; The only difference between the two formulas was that in patients with preserved ejection fraction&#44; CKD-EPI predicted mortality more accurately&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">43</span></a> In another study that evaluates up to 5 formulas for calculating eGFR&#44; this was a predictor of mortality for all of them&#58; the most accurate was that of Cockroft-Gault&#44; which includes the weight of the patient&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">44</span></a> In obese patients&#44; this formula calculates a greater eGFR than the rest of the formulas for a specific creatinine&#44; which could explain the so-called paradox of obesity in the estimation of the risk of death in AHF&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">45</span></a> That is&#44; a higher weight is associated with lower mortality&#44; given the lower estimated renal dysfunction&#46; Finally&#44; as discussed below&#44; it is important to mention that the addition of cystatin C to the CKD-EPI formula improves its prognostic ability&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Criteria for acute kidney injury</span><p id="par0080" class="elsevierStylePara elsevierViewall">The NICE criteria recommend defining the magnitude of renal involvement in dynamic terms&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">46</span></a> This would be the objective of the term AKI and for its definition different criteria have been published &#40;RIFLE&#44; AKIN and KDIGO&#41; which are the ones that have been used <span class="elsevierStyleItalic">a posteriori</span> to evaluate its prognostic meaning&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">23</span></a><a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a> summarizes the studies that explore the different AKI criteria&#46; In all of them&#44; the classification is based on the variation of serum creatinine and the volume of diuresis&#46; It seems that the KDIGO criteria may be superior for predicting short-term results&#44; although it is an Asian population study&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">47</span></a> The same authors add that we must bear in mind that the RIFLE criteria were derived and validated in very selected populations&#46; When AKI criteria are compared as an alternative to WRF&#44; defined by the increase in serum creatinine &#8805;0&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; these better identify the severe stages that are associated with adverse events &#40;re-admission due to AHF&#44; use of renal replacement therapy or death from all causes&#41; at 30 days and a year&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">48</span></a> Finally&#44; it should be noted that prediction scores for the occurrence of AKI have been designed&#44; in which prior CKD and the use of diuretics during AHF are particularly relevant&#46;<a class="elsevierStyleCrossRefs" href="#bib0545"><span class="elsevierStyleSup">49&#8211;52</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">New kidney injury biomarkers</span><p id="par0085" class="elsevierStylePara elsevierViewall">In recent years&#44; different biomarkers have been described and researched with the aim of detecting AKI earlier&#44; prior to the variation of creatinine or eGFR&#46; Among these new biomarkers are <span class="elsevierStyleItalic">neutrophil gelatinase-associated lipocalin</span> &#40;NGAL&#41; and Cystatin C&#46;<a class="elsevierStyleCrossRef" href="#bib0565"><span class="elsevierStyleSup">53</span></a><a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a> shows several new kidney injury biomarkers&#46;</p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">Plasma NGAL is a protein from the renal tubule&#46; The AKINESIS study was designed with the assumption that the increase in serum creatinine in the context of AHF might not reflect a true AKI and&#44; therefore&#44; would not have a prognostic value in all cases&#46; Their results demonstrate that plasma NGAL is not superior to creatinine in terms of predicting worsening renal function or adverse in-hospital outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">54</span></a> NGAL can also be determined in urine and&#44; in this case&#44; it could be more useful&#46; Its increase at admission or at 12&#8211;24<span class="elsevierStyleHsp" style=""></span>h of treatment is associated with a WRF at 5 days&#44; defined according to the RIFLE criteria&#44; or by a variation in serum creatinine &#8805;0&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; This increase in urine NGAL is also associated with more adverse events at 30 days&#46; For all these reasons&#44; the authors postulate that treatment should be individualized in patients with AHF and renal dysfunction&#44; especially in the first 12&#8211;24<span class="elsevierStyleHsp" style=""></span>h&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">55</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">The use of cystatin C in the CKD-EPI formula in a Spanish cohort of 613 patients with AHF increases the predictive accuracy to independently detect death from any cause or re-admission for AHF&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">56</span></a> The same research group compares the CKD-EPI formulas&#44; with or without cystatin C&#44; and MDRD and concludes that the use of cystatin C can more accurately predict the risk of adverse events&#44; especially in patients with relatively preserved renal function&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">57</span></a> This finding is similar to that of Breidthardt et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">58</span></a> taking into account that cystatin C did not predict AKI&#44; but long-term mortality&#46; Even in patients with normal creatinine&#44; increased cystatin C was predictive of death from any cause at 1 year and&#44; consequently&#44; its usefulness would extend beyond the first hours or days after the acute event&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">59</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">The carbohydrate antigen 125 &#40;CA125&#41; has been evaluated as a marker of systemic congestion and may be helpful for the titration of diuretics&#46; In order to develop a tool for the titration of diuretics and based on the idea that the benefit of diuretics would depend on the renal status on admission and the degree of congestion&#44; a study of 526 consecutive patients admitted for AHF&#44; who received intravenous furosemide in the first 48<span class="elsevierStyleHsp" style=""></span>h&#44; was carried out&#46; The study evaluated whether the early changes in creatinine associated with furosemide differed between the groups defined by volume overload with a CA125 &#62;35<span class="elsevierStyleHsp" style=""></span>U&#47;ml and a creatinine &#8805;1&#46;4<span class="elsevierStyleHsp" style=""></span>mg&#47;dl on admission&#46; The results of the study show that the effect of furosemide differed according to the concentration of CA125&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">60</span></a></p></span></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conclusion</span><p id="par0105" class="elsevierStylePara elsevierViewall">As a conclusion of our review we can say that renal dysfunction in the context of AHF&#44; defined from the variations in creatinine&#44; eGFR or AKI criteria&#44; is a variable associated with a worse prognosis&#44; especially when it is associated with congestion&#44; a phenomenon that can be explained by neurohormonal activation and confirmed by an increase in the BUN&#47;creatinine ratio&#46; In addition to predisposing to a worsening of multifactorial origin&#44; a previous CKD could also predict a group with worse prognosis&#46; Other new biomarkers&#44; such as those that identify tubular damage or congestion&#44; have been able to increase the discriminative capacity of predictive models for AHF&#44; but they are still of limited use in routine clinical practice&#44; awaiting studies with more conclusive results&#46; It would probably be necessary to define the renal dysfunction profile so as to determine whether it is actually an established renal injury&#44; due to a specific treatment&#44; or a transitory phenomenon related to volume overload&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflict of interests</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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              "titulo" => "Urea nitrogen and urea nitrogen&#47;creatinine ratio"
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              "titulo" => "Chronic kidney disease"
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              "titulo" => "Formula for calculating the estimated glomerular filtration rate"
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            0 => "Renal function"
            1 => "Acute heart failure"
            2 => "Outcome"
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            1 => "Insuficiencia cardiaca aguda"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The interaction between acute heart failure &#40;AHF&#41; and renal dysfunction is complex&#46; Several studies have evaluated the prognostic value of this syndrome&#46; The aim of this systematic review&#44; which includes non-selected samples&#44; was to investigate the impact of different renal function variables on the AHF prognosis&#46; The categories included in the studies reviewed included&#58; creatinine&#44; blood urea nitrogen &#40;BUN&#41;&#44; the BUN&#47;creatinine quotient&#44; chronic kidney disease&#44; the formula to estimate the glomerular filtration rate&#44; criteria of acute renal injury and new biomarkers of renal damage such as neutrophil gelatinase-associated lipocalin &#40;NGAL and cystatin c&#41;&#46; The basal alterations of the renal function&#44; as well as the acute alterations&#44; transient or not&#44; are related to a worse prognosis in AHF&#44; it is therefore necessary to always have baseline&#44; acute and evolutive renal function parameters&#46;</p></span>"
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      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La insuficiencia cardiaca aguda &#40;ICA&#41; y la disfunci&#243;n renal son 2<span class="elsevierStyleHsp" style=""></span>entidades para cuya compleja interacci&#243;n se ha explorado su valor pron&#243;stico&#46; El objetivo de esta revisi&#243;n sistem&#225;tica de trabajos&#44; que parte de muestras no seleccionadas&#44; fue investigar el impacto que tienen diversas variables de funci&#243;n renal sobre el pron&#243;stico de la ICA&#46; La creatinina&#44; el nitr&#243;geno ureico &#40;BUN&#41;&#44; el cociente BUN&#47;creatinina&#44; la enfermedad renal cr&#243;nica&#44; la f&#243;rmula para estimar la tasa de filtrado glomerular&#44; los criterios de lesi&#243;n renal aguda y los nuevos biomarcadores de da&#241;o renal &#40;NGAL y la cistatina C&#41; son las categor&#237;as en que se han incluido los trabajos revisados&#46; Las alteraciones basales&#44; as&#237; como las alteraciones agudas&#44; transitorias o no&#44; de la funci&#243;n renal se relacionan con un peor pron&#243;stico en la ICA&#46; Es&#44; por lo tanto&#44; necesario tener siempre par&#225;metros de funci&#243;n renal basales&#44; del episodio agudo y evolutivos&#46;</p></span>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Llauger L&#44; Jacob J&#44; Mir&#243; &#210;&#46; Funci&#243;n renal y pron&#243;stico de los episodios de insuficiencia cardiaca aguda&#46; Med Clin &#40;Barc&#41;&#46; 2018&#46; <a class="elsevierStyleInterRef" target="_blank" id="intr0005" href="https://doi.org/10.1016/j.medcli.2018.05.010">https&#58;&#47;&#47;doi&#46;org&#47;10&#46;1016&#47;j&#46;medcli&#46;2018&#46;05&#46;010</a></p>"
      ]
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Search strategy&#46;</p> <p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">BUN&#44; <span class="elsevierStyleItalic">blood urea nitrogen</span>&#59; Cr&#44; creatinine&#59; CysC&#44; cystatin C&#59; AHF&#44; acute heart failure&#59; NGAL&#44; <span class="elsevierStyleItalic">neutrophil gelatinase-associated lipocalin</span>&#59; eGFR&#44; estimated glomerular filtration rate&#46;</p>"
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        "etiqueta" => "Table 1"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">WRF&#44; worsening renal function&#59; CKD&#44; chronic kidney disease&#59; AHF&#44; acute heart failure&#59; AKI&#44; acute kidney injury&#59; IRF&#44; improved renal function&#59; NYHA&#44; New York Heart Association&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Design&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Centers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sample &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Main hypotheses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results RR&#44; OR&#44; HR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metra et al&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2003&#8211;2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">318&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">WRF incidence&#44; prognostic value at one-year&#44; clinical characteristics and risk factors in AHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HR 1&#46;47 &#40;1&#46;13&#8211;1&#46;81&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;024&#41; for WRF and death or re-admission&#46;<br>OR 1&#46;84 &#40;1&#46;04&#8211;3&#46;27&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&#41; in CKD&#44; OR 2&#46;18 &#40;1&#46;27&#8211;3&#46;73&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;004&#41; if furosemide&#44; OR 2&#46;07 &#40;1&#46;24&#8211;3&#46;45&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#41; in NYHA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">WRF in absolute &#40;&#8805;0&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; and relative &#40;&#8805;25&#37;&#41; value predicted death and re-admission&#46;<br>The predictors of WRF were CKD&#44; furosemide and NYHA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Berra et al&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">25</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Switzerland&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">646&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prognostic value of WRF in patients admitted for AHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HR 1&#46;29 &#40;1&#46;13&#8211;1&#46;47&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0002&#41; for AKI&#46;<br>HR 1&#46;24 &#40;1&#46;06&#8211;1&#46;45&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;0059&#41; for WRF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AKI and WRF were those most related to mortality and re-admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Freda et al&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2008&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts &#40;Cerner Health Facts&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">14&#44;017&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To describe the incidence and results at discharge of persistent or transient AKI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RR 1&#46;29 &#40;1&#46;17&#8211;1&#46;42&#41; for persistent AKI&#44; RR 1&#46;14 &#40;1&#46;00&#8211;1&#46;31&#41; transient AKI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Both transient and persistent AKI represent a greater risk of re-admission at 30 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Krishnamoorthy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2001&#8211;2006&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts &#40;ADHERE registry&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;&#62;300&#41; linked to Medicare&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">27&#44;309&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To describe the prevalence and characteristics of patients with transient or persistent WRF and compare results at 90 days&#44; non-WRF&#44; transient or persistent WRF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HR 1&#46;19 &#40;1&#46;05&#8211;1&#46;35&#41; for transient WRF&#46;<br>HR 1&#46;73 &#40;1&#46;57&#8211;1&#46;91&#41; for persistent WRF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Transient or persistent WRF have been associated with poorer outcomes&#44; especially in persistent cases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metra et al&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2005&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">599&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evaluate WRF interaction and congestion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HR 2&#46;44 &#40;1&#46;24&#8211;4&#46;18&#41; for mortality&#46;<br>HR 1&#46;39 &#40;0&#46;88&#8211;2&#46;2&#41; for mortality and readmission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">WRF predicts the prognosis of death or readmission in patients with congestion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wattad et al&#46;<a class="elsevierStyleCrossRef" href="#bib0445"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2008&#8211;2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Israel&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">762&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Persistent WRF and congestion could be associated with worse prognosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HR 4&#46;16 &#40;2&#46;20&#8211;7&#46;86&#41; in WRF with persistent congestion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Persistent WRF and congestion were associated with higher mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Testani et al&#46;<a class="elsevierStyleCrossRef" href="#bib0450"><span class="elsevierStyleSup">30</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2004&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">903&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To describe the MFR and risk of death associated&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OR 4&#46;2 &#40;2&#46;6&#8211;6&#46;7&#41; in previous WRF and OR 1&#46;8 &#40;1&#46;2&#8211;2&#46;7&#41; in post-admission WRF&#46;<br>HR 1&#46;3 in IRF and death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline congestion and volume of diuresis were associated with pre&#47;post-admission IRF and WRF&#46;<br>IRF was associated with a higher risk of death and&#44; on discharge&#44; a greater worsening in eGFR&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Studies that analyze the prognostic significance of serum creatinine in acute heart failure&#46;</p>"
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          "leyenda" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">BNP&#44; brain natriuretic peptide&#59; BUN&#44; <span class="elsevierStyleItalic">blood urea nitrogen</span>&#59; Cr&#44; creatinine&#59; RD&#44; renal dysfunction&#59; AHF&#44; acute heart failure&#59; IH&#44; in-hospital&#59; HR&#44; heart rate&#59; AKI&#44; acute kidney injury&#59; IRF&#44; improved renal function&#59; SBP&#44; systolic blood pressure&#59; eGFR&#44; estimated glomerular filtration rate&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Design&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Centers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sample &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Main hypotheses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results RR&#44; OR&#44; HR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Arenja et al&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">31</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2001&#8211;2002<br>2006&#8211;2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Switzerland&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">610&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Utility of a simple algorithm in non-selected AHF&#44; in relation to 1-year mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HR 2 &#40;1&#46;7&#8211;2&#46;4&#41; for death in high BUN and advanced age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BUN was the best predictor of death at 1-year&#46; The highest risk groups had the highest BUN &#40;&#62;27&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; and the highest age &#40;&#62;86 years&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chioncel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2008&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Romania&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts &#40;RO-AHFS registry&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3224&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Epidemiology&#44; symptoms&#44; management and progression of patients with AHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OR 0&#46;488 &#40;1&#46;002&#8211;1&#46;015&#41; in baseline renal dysfunction &#40;BUN&#41; and death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline BUN was a predictor of IH death from any cause&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Heywood et al&#46;<a class="elsevierStyleCrossRef" href="#bib0465"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2001&#8211;2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts &#40;ADHERE registry&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;280&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">118&#44;465&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prevalence and severity of renal dysfunction on admission&#44; the relationship with treatments and in-hospital outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OR 1&#46;18 &#40;1&#46;17&#8211;1&#46;20&#41; if decrease of 10<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> in GFR&#46;<br>As an isolated predictor&#44; statistical C 0&#46;70 in BUN and IH death<br>Model with 4 variables&#44; statistical C 0&#46;73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline eGFR was an independent predictor of IH death&#44; but the best was BUN&#46;<br>The best predictive model consisted of BUN&#44; SBP&#44; HR and age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Takaya et al&#46;<a class="elsevierStyleCrossRef" href="#bib0470"><span class="elsevierStyleSup">34</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2006&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">371&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">BUN&#47;Cr ratio or BUN or Cr for mortality risk in AKI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HR 4&#46;71 &#40;2&#46;25&#8211;10&#46;2&#41; for AKI with high BUN&#47;Cr&#46;<br>HR 4&#46;26 &#40;1&#46;99&#8211;9&#46;76&#41; AKI and high BUN&#46;<br>HR 4&#46;15 &#40;1&#46;90&#8211;9&#46;81&#41; and high Cr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AKI with a high BUN&#47;Cr ratio was associated with a higher mortality&#46;<br>AKI&#44; independently of BUN or Cr&#44; was associated with a higher mortality&#46;<br>BUN&#47;Cr could be useful to stratify the risk in AKI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Brisco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">35</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2004&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">896&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To determine if a high BUN&#47;Cr can identify the reversible RD&#46;<br>To validate that RD associated with increased BUN&#47;Cr is associated with a worse prognosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OR 1&#46;5 &#40;1&#46;3&#8211;1&#46;8&#41; for high BUN&#47;Cr and IRF&#46; HR 2&#46;2 &#40;1&#46;6&#8211;3&#46;1&#41; for mortality if high BUN&#47;Cr and eGFR &#60;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A high BUN&#47;Cr allows identifying the group with IRF&#44; but it seems to be a transient phenomenon&#44; associated with higher mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Testani et al&#46;<a class="elsevierStyleCrossRef" href="#bib0480"><span class="elsevierStyleSup">36</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2004&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">908&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To determine if the combination BNP and BUN&#47;Cr allows to identify the group of higher&#47;lower risk with RD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HR 1&#46;8 &#40;1&#46;2&#8211;2&#46;7&#41; worse survival&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The risk of death of RD in AHF can be stratified from BUN&#47;Cr and BNP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Miura et al&#46;<a class="elsevierStyleCrossRef" href="#bib0485"><span class="elsevierStyleSup">37</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts &#40;Tohoku Acute Heart Failure registry&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">337&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Evaluation of changes in BUN as a prognostic factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HR 2&#46;94 &#40;1&#46;51&#8211;5&#46;73&#41; for mortality from any cause if high BUN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Increases in BUN during hospitalization represent a worse prognosis&#44; independently of the calculation of renal function based on Cr at admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Studies analysing the prognostic significance of blood urea nitrogen &#40;BUN&#41; and the BUN&#47;creatinine ratio&#46;</p>"
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          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">CKD-EPI&#44; <span class="elsevierStyleItalic">Chronic Kidney Disease Epidemiology Collaboration</span>&#59; Cr&#44; Creatinine&#59; DM&#44; diabetes mellitus&#59; WRF&#44; worsening renal function&#59; CKD&#44; chronic kidney disease&#59; AHF&#44; acute heart failure&#59; IH&#44; in-hospital&#59; MDRD&#44; <span class="elsevierStyleItalic">Modification of Diet in Renal Disease Study</span>&#59; IRF&#44; improved renal function&#59; SBP&#44; systolic blood pressure&#59; eGFR&#44; estimated glomerular filtration rate&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Design&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Centers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sample &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Main hypotheses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results RR&#44; OR&#44; HR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cioffi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0490"><span class="elsevierStyleSup">38</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2009&#8211;2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Italy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts &#40;IN-HF Outcome record&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;61&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">455&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Clinical characteristics and prognostic markers of short and medium-term mortality in severe renal dysfunction &#40;eGFR &#60;40<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">A 13&#46;6&#37; IH death and 43&#46;5&#37; 1-year death if severe renal dysfunction&#44;<br>OR 0&#46;95 &#40;0&#46;919&#8211;9&#46;83&#41; for eGFR and IH death&#44; in this group of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The in-hospital mortality and at 1-year in patients with severe renal dysfunction was double&#46; The variables related to IH death were low level of consciousness&#44; age&#44; SBP&#44; hyponatremia and eGFR&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">De Miguel-Yanes et al&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">39</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2006&#8211;2007&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Minimum basic data set&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;all hospitals&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">275&#44;176&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To assess the possible interaction of DM CKD in the mortality of AHF admissions&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OR 1&#46;01 &#40;0&#46;91&#8211;1&#46;10&#41; in CKD and DM&#44; OR 1&#46;46 &#40;1&#46;39&#8211;1&#46;53&#41; for CKD and IH death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CKD was associated with higher in-hospital mortality&#44; without being clearly related to DM&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Reid et al&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">40</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2009&#8211;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Canada&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">952&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Meaning of WRF&#47;IRF according to GFR &#60;45 on admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Survival 13&#46;9 months &#40;8&#8211;25&#41; if WRF and 32&#46;5 months &#40;19&#8211;56&#41; if IRF&#44; in GFR &#60;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Changes in renal function were only significant if baseline worsening &#40;GFR &#60;45<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&#44; with greater survival if there was IRF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Inohara et al&#46;<a class="elsevierStyleCrossRef" href="#bib0505"><span class="elsevierStyleSup">41</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2007&#8211;2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts &#40;ATTEND registry&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;53&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4321&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Differences in the prognostic impact of renal dysfunction in IH mortality&#44; according to low perfusion profiles <span class="elsevierStyleItalic">versus</span> kidney congestion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OR 2&#46;36 &#40;1&#46;75&#8211;3&#46;18&#41; for baseline renal dysfunction and IH death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline renal dysfunction&#44; independently of the mechanism&#44; was associated with higher in-hospital mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Closed et al&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">43</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2008&#8211;2013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RICA Cohort&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;52&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1805&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CKD-EPI <span class="elsevierStyleItalic">versus</span> MDRD&#44; and prediction of risk of death in AHF with or without ventricular dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HR 1&#46;55 &#40;1&#46;23&#8211;1&#46;94&#41; if eGFR 30&#8211;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; HR 2&#46;31 &#40;1&#46;71&#8211;3&#46;10&#41; if eGFR &#60;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> for MDRD-4&#46;<br>HR 1&#46;58 &#40;1&#46;24&#8211;2&#46;01&#41; if eGFR 30&#8211;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#44; HR 2&#46;34 &#40;1&#46;75&#8211;3&#46;01&#41; if eGFR &#60;30<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span> for CKD-EPI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">eGFR with both formulas was associated with higher 1-year mortality if renal dysfunction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Weidmann et al&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">44</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">N&#47;A&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">International&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1104&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">eGFR with the Cockroft-Gault formula&#44; predicts post-discharge outcomes better than MDRD-4&#44; MDRD-6&#44; CKD-EPI&#47;BIS-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Death and eGFR 30&#8211;60<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#47;1&#46;73<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span><br>HR 1&#46;44 &#40;0&#46;66&#8211;2&#46;80&#41; C-G<br>HR 1&#46;26 &#40;0&#46;84&#44;188&#41; MDRD-4<br>HR 2&#46;23 &#40;1&#46;60&#8211;3&#46;10&#41; MDRD-6<br>HR 1&#46;02 &#40;0&#46;52&#8211;2&#46;02&#41; CKD-EPI&#47;BIS-1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">EGFR was an independent predictor of mortality with any formula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Cr&#44; creatinine&#59; DM2&#44; type 2 diabetes mellitus&#59; WRF&#44; worsening renal function&#59; CKD&#44; chronic kidney disease&#59; AHF&#44; acute heart failure&#59; IH&#44; in-hospital&#59; AKI&#44; acute kidney injury&#59; SBP&#44; systolic blood pressure&#59; eGFR&#44; estimated glomerular filtration rate&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Design&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Centers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sample &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Main hypotheses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">RR&#44; OR&#44; HR &#40;95&#37; CI&#41; results&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Li et al&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">47</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2008&#8211;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To determine if the KDIGO criteria for identifying and predicting short-term CRS type 1 were superior to the RIFLE or AKIN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RIFLE OR 2&#46;56 &#40;1&#46;79&#8211;3&#46;65&#41;&#59; AKIN OR 2&#46;68 &#40;1&#46;86&#8211;3&#46;84&#41;&#59; KDIGO 3&#46;22 &#40;2&#46;24&#8211;4&#46;62&#41;&#59; subgroup only identified by KDIGO OR 3&#46;24 &#40;1&#46;97&#8211;5&#46;35&#41; for IH death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AKI was associated with higher mortality&#46;<br>The new KDIGO criteria were superior in predicting short-term results in CRS type 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Roy et al&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">48</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2002&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Ireland&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">637&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Epidemiology of AKI using new definitions&#44; in addition to examining the association between severity and main clinical outcomes at 30 days and a year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Risk of adverse events in stage 2 AKI was 4<span class="elsevierStyleHsp" style=""></span>times higher&#44; RIFLE OR 17&#46;7 &#40;8&#46;1&#8211;38&#46;4&#41;&#59; KDIGO OR 19&#46;4 &#40;7&#46;6&#8211;48&#46;6&#41;&#59; AKIN OR 17&#46;6 &#40;7&#8211;44&#46;1&#41; than stage 2 AKI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">AKI with any definition was associated with an increase in risk at 30 days and a year&#46; Few differences were observed in the direct criteria comparison&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Forman et al&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">49</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1997&#8211;1998&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;11&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To determine the prevalence of WRF in AHF admissions&#44; predictive factors for WRF and in-hospital outcomes associated with WRF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RR 7&#46;5 &#40;2&#46;9&#8211;19&#46;3&#41; for death&#44; RR 2&#46;1 &#40;1&#46;5&#8211;3&#41; for IH complications&#44; RR 3&#46;2 &#40;2&#46;2&#8211;4&#46;9&#41; for stays &#62;10 days&#44; in patients with WRF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">WRF risk factors&#58; heart failure&#44; DM2&#44; admission Cr&#44; SBP &#62;160<span class="elsevierStyleHsp" style=""></span>mmHg&#46; WRF was associated with increased IH death&#44; IH complications&#44; stay &#62; 10 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breidthardt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">50</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2001&#8211;2002<br>2006&#8211;2010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Switzerland&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">657&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Prevalence and WRF effect on survival&#46;<br>To establish a risk <span class="elsevierStyleItalic">score</span> for WRF and validate the Forman <span class="elsevierStyleItalic">score</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">HR 1&#46;92 &#40;1&#46;29&#8211;2&#46;59&#41; for WRF and death&#46;<br>Previous CKD was related to WRF&#44; HR 2&#46;07 &#40;1&#46;29&#8211;3&#46;30&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CKD was the only independent predictor of WRF&#46;<br>Mortality was related to eGFR&#44; and WRF strengthened this effect&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Wang et al&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">51</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2004&#8211;2011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1709&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Design and validate a <span class="elsevierStyleItalic">score</span> of prediction of AKI in AHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">OR 3&#46;11 &#40;2&#46;23&#8211;4&#46;35&#41; for baseline Cr &#62;1&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; OR 1&#46;96 &#40;1&#46;16&#44; 3&#46;30&#41; for furosemide &#62;80<span class="elsevierStyleHsp" style=""></span>mg&#47;day and OR 2&#46;09 &#40;1&#46;31&#44; 3&#46;33&#41; if re-examination&#44; in the prediction of AKI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Baseline Cr &#62;1&#46;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#44; furosemide &#62;80<span class="elsevierStyleHsp" style=""></span>mg&#47;day and re-examination were predictors of AKI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Zhou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">52</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2011&#8211;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">China&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">676&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To develop and validate a risk <span class="elsevierStyleItalic">score</span> for AKI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CKD&#44; OR 4&#46;15 &#40;2&#46;36&#8211;7&#46;28&#41; to predict AKI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Previous CKD was included in the <span class="elsevierStyleItalic">score</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">CA 125&#44; carbohydrate antigen 125&#59; CKD-EPI&#44; <span class="elsevierStyleItalic">Chronic Kidney Disease Epidemiology Collaboration</span>&#59; Cr&#44; creatinine&#59; CysC&#44; cystatin C&#59; WRF&#44; worsening renal function&#59; FD&#44; furosemide&#59; AHF&#44; acute heart failure&#59; IH&#44; in-hospital&#59; AKI&#44; acute kidney injury&#59; MDRD&#44; <span class="elsevierStyleItalic">Modification of Diet in Renal Disease Study</span>&#59; eGFR&#44; estimated glomerular filtration rate&#59; u&#44; urinary&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Reference&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Year&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Design&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Centers&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sample &#40;<span class="elsevierStyleItalic">n</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Main hypotheses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Results RR&#44; OR&#44; HR &#40;95&#37; CI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Comments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Maisel et al&#46;<a class="elsevierStyleCrossRef" href="#bib0570"><span class="elsevierStyleSup">54</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2010&#8211;2014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multinational&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">927&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NGAL prognostic ability to predict WRF or need for renal replacement therapy&#46;<br>NGAL prognostic ability for adverse IH outcomes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Peak NGAL ROC 0&#46;656&#44; baseline ROC 0&#46;647&#44; baseline Cr ROC 0&#46;652 and WRF<br>For adverse events baseline NGAL ROC 0&#46;691&#44; peak ROC 0&#46;653&#44; first Cr 0&#46;686 and adverse events&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NGAL was not superior to Cr to predict WRF or adverse IH events&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Collins et al&#46;<a class="elsevierStyleCrossRef" href="#bib0575"><span class="elsevierStyleSup">55</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2008&#8211;2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">USA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">399&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urine NGAL would be associated with WRF and worse prognosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NGAL &#40;u&#41; OR 1&#46;02 &#40;1&#46;01&#8211;1&#46;04&#41; for WRF predictor&#46;<br>There are 42 cases with adverse events at 30 days <span class="elsevierStyleItalic">versus</span> 25&#44; NGAL at 12&#8211;24<span class="elsevierStyleHsp" style=""></span>h&#44; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;035&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">NGAL &#40;u&#41; at 12&#8211;24<span class="elsevierStyleHsp" style=""></span>h was a predictor of WRF and adverse events at 30 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Flores-Blanco et al&#46;<a class="elsevierStyleCrossRef" href="#bib0580"><span class="elsevierStyleSup">56</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2006&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">613&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To assess whether the CKD-EPI formula based on the Cys-C provides additional information&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CKD-EPI SCr-CysC HR 0&#46;998 &#40;0&#46;983&#8211;0&#46;994&#41; for death or re-admission for AHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The CKD-EPI formula based on Cys-C to estimate eGFR is an independent predictor of adverse outcomes in AHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Manzano-Fern&#225;ndez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0585"><span class="elsevierStyleSup">57</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2006&#8211;2009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">526&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To evaluate whether CKD-EPI based on Cr or CysC predicts the risk of adverse events better than MDRD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CKD-EPI Cr-CysC HR 0&#46;984 &#40;0&#46;979&#8211;0&#46;989&#41; and MDRD HR 0&#46;991 &#40;0&#46;986&#8211;0&#46;985&#41; in death or re-admission&#44; but in Kapplan-Meier curves log rank test <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;001 with formulas that include CysC <span class="elsevierStyleItalic">vs&#46; p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;374 in CKD-EPI only with Cr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">eGFR was a predictor of mortality and re-admission&#44; independently of the formula&#44; but this was improved by incorporating formulas based on CysC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Breidthardt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0590"><span class="elsevierStyleSup">58</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Switzerland&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">207&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To examine the diagnostic and prognostic importance of plasma CysC levels in relation to serum Cr levels in AHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">ROC curve for AKI with Cr was 0&#46;68 &#40;0&#46;58&#8211;0&#46;78&#41; and with CysC 0&#46;67 &#40;0&#46;58&#8211;0&#46;76&#41;<br>CysC HR 1&#46;41 &#40;1&#46;02&#8211;1&#46;95&#41; for death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CysC did not predict AKI but did predict mortality in AHF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lassus et al&#46;<a class="elsevierStyleCrossRef" href="#bib0595"><span class="elsevierStyleSup">59</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Finland&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts &#40;FINN-AKVA registry&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Multicentre &#40;13&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">480&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CysC prognostic impact compared to Cr and eGFR&#46; To verify that normal Cr &#43; high CysC is associated with an increased risk of death&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CysC HR 3&#46;2 &#40;2&#46;0&#8211;5&#46;3&#41;&#46;<br>Kaplan&#8211;Meier curve with normal Cr &#43; high CysC log rank test <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CysC was associated with higher IH mortality at 30 days and a year&#44; with greater predictive power than Cr or eGFR&#46;<br>They also identified patients with worse prognosis despite having normal Cr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nu&#241;ez et al&#46;<a class="elsevierStyleCrossRef" href="#bib0600"><span class="elsevierStyleSup">60</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">2010&#8211;2012&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Cohorts&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Single center&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">526&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">To assess whether the early changes in Cr associated with FD differ between the groups defined by volume overload &#40;CA125&#41; and creatinine on admission&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">For high Cr&#44; if CA 125 was high HR 0&#46;84 &#40;0&#46;71&#8211;0&#46;99&#41; when FD dose was increased&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">&#916;Cr due to FD was determined by congestion&#46;<br>Renal dysfunction on admission&#44; despite WRF&#44; after FD&#44; improved renal function&#46;<br>FD proved more beneficial at high doses the greater the congestion due to a reduction of mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">New biomarkers&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:60 [
            0 => array:3 [
              "identificador" => "bib0305"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure&#58; The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology &#40;ESC&#41; Developed with the special contribution of the Heart Failure Association &#40;HFA&#41; of the ESC"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Ponikowski"
                            1 => "A&#46;A&#46; Voors"
                            2 => "S&#46;D&#46; Anker"
                            3 => "H&#46; Bueno"
                            4 => "J&#46;G&#46;F&#46; Cleland"
                            5 => "A&#46;J&#46;S&#46; Coats"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Eur Heart J"
                        "fecha" => "2016"
                        "volumen" => "18"
                        "paginaInicial" => "891"
                        "paginaFinal" => "975"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0310"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Caracter&#237;sticas cl&#237;nicas&#44; terap&#233;uticas y evolutivas de los pacientes con insuficiencia cardiaca aguda atendidos en servicios de urgencias espa&#241;oles&#58; Registro EAHFE &#40;Epidemiology of Acute Heart Failure in Spanish Emergency Departments&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Llorens"
                            1 => "R&#46; Escoda"
                            2 => "O&#46; Mir&#243;"
                            3 => "P&#46; Herrero-Puente"
                            4 => "F&#46;J&#46; Mart&#237;n-S&#225;nchez"
                            5 => "J&#46; Jacob"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Emergencias"
                        "fecha" => "2015"
                        "volumen" => "27"
                        "paginaInicial" => "11"
                        "paginaFinal" => "22"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29077328"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0315"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Multidisciplinary approach for patients hospitalized with heart failure"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "L&#46; Frankenstein"
                            1 => "H&#46; Fr&#246;hlich"
                            2 => "J&#46;G&#46; Cleland"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rec.2015.05.008"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Cardiol"
                        "fecha" => "2015"
                        "volumen" => "68"
                        "paginaInicial" => "885"
                        "paginaFinal" => "891"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26409892"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Acute heart failure deserves a log-scale boost in research support&#58; call for multidisciplinary and universal actions"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "A&#46; Mebazaa"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.jchf.2017.09.012"
                      "Revista" => array:6 [
                        "tituloSerie" => "JACC Heart Fail"
                        "fecha" => "2018"
                        "volumen" => "6"
                        "paginaInicial" => "76"
                        "paginaFinal" => "79"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29284580"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evolution of the clinical profile of patients with acute heart failure treated in Spanish emergency departments"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Escoda"
                            1 => "&#210;&#46; Mir&#243;"
                            2 => "F&#46;J&#46; Mart&#237;n-S&#225;nchez"
                            3 => "J&#46; Jacob"
                            4 => "P&#46; Herrero"
                            5 => "V&#46; Gil"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.rce.2016.10.008"
                      "Revista" => array:7 [
                        "tituloSerie" => "Rev Clin Esp"
                        "fecha" => "2017"
                        "volumen" => "217"
                        "paginaInicial" => "127"
                        "paginaFinal" => "135"
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