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

Background: Outcomes associated with worsening renal function (WRF) in cardiogenic shock (CS) remain poorly understood. Objectives: To study the incidence of WRF in heart failure-CS (HF-CS) and acute myocardial infarction CS (AMI-CS), examine its association with in-hospital mortality (IHM) rates, define the trajectory of renal function in CS, and identify independent predictors of WRF in HF-CS vs AMI-CS. Methods: Patients in the Cardiogenic Shock Working Group registry (CSWG) from 2021–2024 were analyzed; those with baseline end-stage renal disease were excluded. WRF was defined as an increase in creatinine ≥ 0.3 mg/dL, a decrease in estimated glomerular filtration rate (eGFR) > 25%, or initiation of renal replacement therapy (RRT) within 72 hours of CS diagnosis. Results: Of 6269 patients with CS, 35% developed WRF, including 32% of patients with HF-CS and 41% of patients with AMI-CS. Patients who developed WRF were more likely to have been transferred from other hospitals (63% vs 50%; P < 0.001). Baseline right atrial pressure (RAP) was higher in patients with both HF-CS (15 mmHg vs 12 mmHg; P < 0.001) and AMI-CS (13 mmHg vs 11 mmHg; P = 0.02) and with WRF compared to patients without WRF. The incidence of WRF was higher in patients exposed to both tMCS and vasoactive agents as compared to vasoactive drugs alone (46% vs 29%; P < 0.001). The overall rate of RRT initiation was 20% throughout admission, with higher rates in patients with acute on chronic vs de novo HF-CS and in patients with ST-elevation myocardial infarction (STEMI)-CS vs NSTEMI-CS in the first 24 hours. IHM was higher in patients with WRF (41% vs 21%; P < 0.001). In patients with WRF, median eGFRs declined steadily throughout the first 72 hours after diagnosis of CS. Key independent predictors of WRF included RAP, lactate levels and transfer status in patients with HF-CS and CKD and lactate and transfer status in patients with AMI-CS. Conclusion: WRF is common and deleterious in both HF- and AMI-CS. Given the early association with worse outcomes, WRF may be not only prognostic but may also represent a potential therapeutic target in future studies of CS.