Total Bilirubin and CHF

Q:  Elevated total bilirubin is associated with increased risk of death in advanced Congestive Heart Failure (CHF).

A) True

B) False

Answer: A

At least four blood tests, either combined or alone, predict a worse outcome in advanced CHF.

• Rising serum creatinine
• Hyponatremia 
• Hypoalbuminemia 
• Elevated total bilirubin

Neurohormonal adaptations, reduced renal perfusion, increased renal venous pressure, and right ventricular dysfunction result in a lower Glomerular Filtration Rate (GFR) and higher blood urea nitrogen (BUN), both of which have been associated with increased mortality and worse prognosis in CHF. This may get complicated by high-dose diuresis for refractory volume overload. Renal compromise and volume overload result in hyponatremia, which itself is associated with worse outcomes in this population of patients. Once hypoalbuminemia goes at ≤3.4 mg/dL, also becomes a marker for poor prognosis. Hypoalbuminemia results from decreased liver synthesis, increased vascular permeability, increased degradation, and renal and gastrointestinal loss. 

Advanced CHF results in congestive hepatopathy due to Right-sided failure, which often accompanies left-sided failure. Abnormalities in serum aminotransferase levels, serum alkaline phosphatase, and total bilirubin are given, and elevated total bilirubin is associated with increased risk of death in HF.

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References:

1. Filippatos G, Rossi J, Lloyd-Jones DM, et al. Prognostic value of blood urea nitrogen in patients hospitalized with worsening heart failure: insights from the Acute and Chronic Therapeutic Impact of a Vasopressin Antagonist in Chronic Heart Failure (ACTIV in CHF) study. J Card Fail 2007; 13:360.

2. Klein L, Massie BM, Leimberger JD, et al. Admission or changes in renal function during hospitalization for worsening heart failure predict postdischarge survival: results from the Outcomes of a Prospective Trial of Intravenous Milrinone for Exacerbations of Chronic Heart Failure (OPTIME-CHF). Circ Heart Fail 2008; 1:25.

3. Uthamalingam S, Kandala J, Daley M, et al. Serum albumin and mortality in acutely decompensated heart failure. Am Heart J 2010; 160:1149.

4. Allen LA, Felker GM, Pocock S, et al. Liver function abnormalities and outcome in patients with chronic heart failure: data from the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) program. Eur J Heart Fail 2009; 11:170.