Heart failure carries tenfold increase in kidney disease risk in T2D

Among individuals with type 2 diabetes (T2D), heart failure is strongly linked to worsening kidney function, such that the risk of end-stage kidney disease (ESKD) soars tenfold following heart failure events, according to a Singapore study.

In a cohort of 1,985 outpatients with T2D, the risk of progression to ESKD was 9.6 times higher for those who had heart failure than for their counterparts who did not experience such an event (hazard ratio [HR], 9.6, 95 percent confidence interval [CI], 5.0–18.3), regardless of cardiorenal risk factors including eGFR and albuminuria. [Cardiovasc Diabetol 2024;23:204]

Notably, the risk was more pronounced in the presence of heart failure with preserved ejection fraction (HR, 13.7, 95 percent CI, 6.3–29.5) vs reduced ejection fraction (HR, 6.5, 95 percent CI, 2.3–18.6).

The excess risk of ESKD rose immediately after the incidence of heart failure, remained elevated for 2 years, and was moderated thereafter.

“At least two plausible mechanisms may underpin the linkage between incident heart failure and the subsequent risk of progression to ESKD,” the investigators noted.

Firstly, elevated central venous pressure from heart failure may lead to renal venous hypertension, increased renal resistance, and impaired intrarenal blood flow, ultimately causing a decline in filtration function as documented in prior research. Secondly, heart failure may activate the sympathetic nervous system and the renin-angiotensin-aldosterone system, which contribute to further disrupt kidney function and promote inflammation and damage. [Circulation 2019;139:e840; Heart Fail Rev 2012;17:411-420]

These findings, together with evidence from the literature, “strongly support the notion that incident heart failure is an important precipitating factor for kidney disease progression in diabetic populations,” the investigators said.

“Clinicians should be aware of the high risk of progression to ESKD in T2D patients with incident heart failure, intensively monitor their kidney function, and minimize nephrotoxic exposure, especially in the first 2 years after onset of heart failure,” they added.

The investigators also stressed the importance of prevention, early detection, and timely treatment of heart failure, given that it is often an unrecognized complication in people with diabetes. [Diabetes Care 2022;45:1670-1690; Circulation 2018;138:2774-2786]

In the study, 180 incident heart failure events and 181 incident ESKD events occurred over a median follow-up of 8.6 years. ESKD was defined as a composite of progression to sustained eGFR below 15 ml/min/1.73m2, maintenance dialysis or renal death, whichever occurred first. Of the ESKD events, 38 (21 percent) occurred after incident heart failure.

“Asian people are known to have high risk of ESKD as compared to European descents. Future studies are needed to assess whether findings from our Asian people with diabetes are generalizable to other ethnic groups,” the investigators said.