#Nephpearls #MedEd ⭐️A decline in kidney function during #heartfailure treatment is not necessarily bad. What matters is whether the patient is being successfully decongested. Apart from laboratory markers, how do you 'see' if the patient is decongested? #POCUS ! Interesting data from EVEREST study - 3,715 patients over 9.9 months follow up. Reference at the bottom of the figure. 🔴1. Top left: Declining eGFR looks bad when examined alone A 30% decline in eGFR was associated with a 19% higher risk of death (HR 1.19). This suggests worsening kidney function is associated with worse outcomes. But this analysis doesn't consider whether the patient was successfully decongested. 🟢2. Top right: Decongestion is associated with better outcomes The investigators looked at two indirect markers of decongestion: ⬇️ BNP: Suggests improvement in cardiac wall stress and congestion. Every halving of BNP was associated with a 22% lower risk of death (HR 0.78). ⬆️ Hematocrit: Suggests hemoconcentration, potentially reflecting plasma volume reduction during diuresis. Every 3% increase was associated with an 11% lower risk of death (HR 0.89). In other words, patients showing evidence of effective decongestion generally had better outcomes. 🔵3. Bottom panel: The most important finding The investigators examined the association between declining eGFR and mortality across different degrees of decongestion. When BNP declined very little: Declining eGFR was associated with higher mortality. This could indicate persistent congestion alongside worsening kidney function. When BNP declined substantially: - The association between declining eGFR and mortality became weaker, approaching neutrality. The same pattern was even clearer with hematocrit: When hematocrit increased very little: - Declining eGFR was associated with increased mortality. When hematocrit increased substantially: - Declining eGFR was no longer clearly associated with increased mortality. The hematocrit interaction was statistically significant (p = 0.012). The BNP interaction showed a similar trend but did not meet the conventional significance threshold (p = 0.074).