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357 at the Centre of Heart Diseases, 4th Military Hos‐ pital, Wrocław, Poland, with a primary diagnosis of AHF, between July 2008 and August 2010 (Sup‐ plementary material, Figure S1). The inclusion cri‐ teria were as follows: age ≥18 years; the diagnosis of AHF based on the European Society of Cardiol‐ ogy criteria as the primary cause of hospitaliza‐ tion8,9; and patient’s written consent to partici‐ pate in the study. The exclusion criteria includ‐ ed: clinical diagnosis of concurrent acute coro‐ nary syndrome; cardiogenic shock; end ‐stage re‐ nal disease requiring renal replacement therapy (or planned renal replacement therapy); and ex‐ posure to nephrotoxic agents during the first 3 days of hospitalization. After confirming the diagnosis of AHF, pa‐ tients were admitted and demographic data, clin‐ ical history, comorbidities, and previous thera‐ pies were recorded. During hospitalization, ev‐ ery patient underwent standard clinical evalua‐ tion and received guideline ‐recommended treat‐ ment.8 The choice of a diuretic regimen was left at a physician’s discretion. The study protocol was approved by the local ethics committee, and the study was conducted in accordance with the Dec‐ laration of Helsinki. Worsening renal function was defined as an increase of 0.3 mg/dl or higher in serum cre‐ atinine levels or a decrease by more than 25% in eGFR (expressed in ml/min/1.73 m2, from the Modification of Diet in Renal Disease equa‐ tion), as compared with the baseline values dur‐ ing the first 3 days of hospitalization. Patients who developed WRF were classified either as having true WRF or pseudo ‐WRF. The former group encompassed patients with simultane‐ ous presence of WHF, defined as deterioration or no improvement of HF signs and symptoms Introduction Organ dysfunction, including renal disturbances, occurs frequently in patients with acute heart failure (AHF),1,2 but the importance of worsening renal function (WRF) has not been well recognized. There is evidence that an increase in creatinine levels is associated with poor out‐ come only if the clinical status of a patient does not improve.3 It has been shown that WRF is re‐ lated to tubular injury, expressed by increased levels of urinary neutrophil gelatinase–associat‐ ed lipocalin and urinary kidney injury molecule 1.4 On the other hand, an increase in creatinine lev‐ els with simultaneous effective decongestion and hemoconcentration is related to better outcome.5 In light of this evidence, WRF can be divided into true WRF and pseudo ‐WRF by the extension of the most commonly used definition of creati‐ nine/estimated glomerular filtration rate (eGFR) changes (approximating to stage 1 acute kidney in‐ jury, proposed by the Acute Kidney Injury Network, or severity class “Risk” according to the RIFLE cri‐ teria [risk, injury, failure, loss of kidney function, end ‐stage kidney disease]) with clinical response to treatment.6 Worsening heart failure (WHF) is a meaningful event during hospitalization for AHF that expresses treatment response. It can be de‐ fined as worsening of symptoms and signs of heart failure (HF) or the lack of improvement that re‐ quires intensification or additional therapy. The condition has been associated with worse outcomes in a few clinical studies.7 We decided to combine these 2 important events (WRF and WHF) and identify patients with true WRF according to the new definition. We also analyzed the predictors and evaluated the predictive role of true WRF.

True worsening renal function identifies patients with acute heart failure with an ominous outcome