The involvement of kidneys in chronic heart failure patients with liver steatosis

Recently, the internist-practitioner does not routinely assess glomerular
filtration rate (GFR) in there no risk factors for chronic kidney disease
(CKD). However, recent data shows that in non-alcoholic fatty liver
disease (NAFLD) it is necessary to assess GFR even without any classic
risk factors for CKD. Early awareness of kidney damage in chronic heart
failure patients (CHF) and NAFLD might help to select those requiring
further investigation and treatment, taking into account comorbidity.
Aim. To assess functional condition of kidneys in CHF patients with liver
steatosis.
Material and methods. Totally, 77 CHF patients included. All patients
had confirmed CHF diagnosis by N-terminal Brain pro-natriuretic peptide
assay. The severity of clinical condition in CHF was assessed, functional
status of patient. All patients underwent clinical and biochemical blood
sampling, electrocardiography, ultrasound liver imaging. The heart
chambers sizes were assessed, walls thickness by echocardiography. All
patients had the GFR by CKD-EPI calculated, as the Fatty Liver Index
(FLI), NAFLD Fibrosis Score (NFS).
Results. More than a half (66%) of patients with CHF had C2 stage of
CKD, 6% — С1, 12% — С3а, 9% — С3б, 4% — С4 stage of CKD. Patients with С5 were absent. Mean GFR was 65,4±14,4 ml/min/1,73 m2. In statistical analysis it was revealed that while there is an increase of SCAHF points, there is parallel increase of CKD stage (p=0,0027). Higher glucose level, higher the stage of CKD (p=0,0022). It was found, that while there is and increase of CKD, right atrium size also increases (p=0,044). With more severe renal damage in CHF, higher the level of PIIINP myocardium fibrosis marker (p=0,047). According to FLI, in 40% of patients there is high chance for liver steatosis, in 34% of patients the data on steatosis was absent, in 26% was intermediate. According to NFS, 26% patients had high probability of liver fibrosis, 9% — did not have, 65% were in a “grey zone”. In analysis of relations there was found that while increasing NFS, GFR does decrease, and CKD stage increases (p=0,049).
Conclusion. Patients with NAFLD and CHF do need GFR assessment.
Early finding of renal involvement in CHF with NAFLD would help to select patients for further investigation and therapy prescription, taking into account comorbidity.

chronic heart failure, chronic kidney disease, N-terminal propetide of collagen III type, Fatty Liver Index, NAFLD Fibrosis Score.

1. Renal function and prediction of cardiovascular risk. Russian guidelines. Cardiovascular Therapy and Prevention 2008; 7(6): 41, Suppl. 3. Russian (Функциональное состояние почек и прогнозирование сердечно-сосудистого риска. Российские рекомендации. Кардиоваскулярная терапия и профилактика 2008; 7(6): 41, Приложение 3).

2. Targher G, Bertolini L, Rodella S, et al. Relationship between kidney function and liver histology in subjects with nonalcoholic steatohepatitis. Clin J Am Soc Nephrol 2010; 5(12): 2166-71.

3. Hwang ST, Cho YK, Yun JW, et al. Impact of non-alcoholic fatty liver disease on microalbuminuria in patients with prediabetes and diabetes. Internal Medicine J 2010; 40(6): 437-42.

4. Mikolasevic I, Racki S, Bubic I, et al. Chronic kidney disease and nonalcoholic Fatty liver disease proven by transient elastography. Kidney Blood Press Res 2013; 37(4-5): 305-10.

5. Targher G, Chonchol M, Zoppini G, et al. Risk of chronic kidney disease in patients with non-alcoholic fatty liver disease: is there a link? J Hepatol 2011; 54(5): 1020-9.

6. Joachim HIx, Sharma K. Mechanisms linking obesity, chronic kidney disease, and fatty liver disease: the roles of fetuin-A, adiponectin, and AMPK. J Am Society of Nephrology 2010; 21(3): 406-12.

7. Angulo P, Hui J, Marchesini G, et al. The NAFLD Fibrosis Score: A Noninvasive System That Identifies Liver Fibrosis in Patients with NAFLD. Hepatology 2007; 4(45): 846-54.

8. Gastaldelli A, Kozakova M, Højlund K, et al. Fatty liver is associated with insulin resistance, risk of coronary heart disease, and early atherosclerosis in a large European population. Hepatology 2009; 49: 1537-44.

9. Balkau B, Lange C, Vol S, et al. Nineyear incident diabetes is predicted by fatty liver indices: the French D.E.S.I.R. study. BMC Gastroenterol 2010; 10: 56 doi: 10.1186/1471-230x-10-56.

10. Calori G, Lattuada G, Ragogna F, et al. Fatty liver index and mortality: the Cremona study in the 15th year of follow-up. Hepatology 2011; 54: 145-52.

11. Drapkina OM, Drapkina YS. Heart and liver fibrosis: the components of the equation. Cardiology 2014; 9: 4-8. Russian (Драпкина О.М., Драпкина Ю.С. Фиброз сердца и печени: составляющие одного уравнения. Кардиология. 2014; 9: 4-8.

12. Drapkina OM, Gegenava BB. Myocardial fibrosis in patients with diabetes. Rational Pharmacotherapy in Cardiology 2013; 9(1): 58-61. Russian (Драпкина О.М., Гегенава Б.Б. Фиброз миокарда у больных с сахарным диабетом. Рациональная фармакотерапия в кардиологии 2013; 9(1): 58-61).

13. Shen Z, Munker S, Luo F, et al. Effect of Non-Alcoholic Fatty Liver Disease on Estimated Glomerular Filtration Rate Could Be Dependent on Age. PLoS One. 2015 Jun 18;10(6):e0130614. doi: 10.1371/journal.pone.0130614. eCollection 2015.

14. Machado M, Gonçalves S, Carepa F, et al. (2012) Impaired renal function in morbid obese patients with nonalcoholic fatty liver disease. Liver Int 32:241-248. doi: 10.1111/j.1478-3231.2011.02623.