Bumetanide Nasal Spray: First Approval.

Salt-retaining states are common medical problems, particularly as clinical manifestations of chronic heart failure (CHF) and chronic kidney disease (CKD). Nephrotic syndrome (NS) in adults is a relatively less common manifestation of kidney disease, with an estimated annual incidence of three new cases per 100,000 [1]. In childhood it is most commonly due to minimal change disease. Most cases of NS in adults are due to primary glomerular diseases, but some are due to secondary glomerular diseases such as diabetes mellitus, systemic lupus erythematosus and amyloidosis [1]. Cardinal features are proteinuria, hypoalbuminaemia and oedema.

Changing etiologies of unexplained adult nephrotic syndrome: A comparison of renal biopsy findings from 1976–1979 and 1995–1997

Subclinical pulmonary congestion is prevalent in nephrotic syndrome.

Community-Acquired Pneumonia

Bumetanide

Background: Focal segmental glomerulosclerosis (FSGS) is a common cause of nephrotic syndrome in adults in Sub-Saharan Africa. The nephrosis usually responds well to steroid therapy but alternative therapy may be needed, following steroid toxicity. Aim: We thus report a case of idiopathic FSGS that manifested as nephrotic syndrome that initially responded to steroid therapy but later was controlled with Azathioprine following steroid-induced psychosis. Findings: Patient was a 32-year old man who developed features of nephrotic syndrome and was found to have biochemical evidence of hypoalbuminemia, low density lipoprotein hypercholesterolemia and nephrotic proteinuria. Renal biopsy histology showed features of FSGS. He was commenced on oral steroid therapy, hematenics, an antiplatelet, a proton pump inhibitor and loop diuretics. Though the edema regressed he developed acute psychosis. The steroid was discontinued, while antipsychotic therapy and Azathioprine were added. The features of psychosis resolved. Nephrosis also remitted. Conclusion: This case report of FSGS that presented as nephrotic syndrome in an adult in Enugu, Nigeria-one of the four cases of steroid-induced psychosis we observed in five years-shows that steroid-induced psychosis is rare in this area and could be addressed by withdrawing the steroid and instituting antipsychotic therapy. It further shows that the nephrosis in idiopathic FSGS could also respond well to isolated Azathioprine therapy in our setting.

Acute decompensated heart failure (ADHF) is a common and highly morbid cardiovascular disorder. Most hospitalizations for ADHF are related to symptoms of congestion, and the vast majority of ADHF patients are treated with intravenous loop diuretics. Despite this nearly ubiquitous use, data supporting the safety and efficacy of loop diuretics in ADHF are limited, and controversy exists about the best way to use loop diuretics with regard to both dosing and means of administration (continuous infusion vs. intermittent boluses). We reviewed the data supporting the safety and efficacy of loop diuretics in patients with ADHF. A large body of observational literature suggests that loop diuretics, especially at higher doses, may be associated with increased mortality in patients with heart failure even after detailed adjustment for other measures of disease severity. Additionally, multiple small underpowered trials suggest that continuous infusion may be equivalent or superior to intermittent bolus dosing. In summary, there is a critical need to develop more robust data on the use of loop diuretics in ADHF. In that context, the NIH Heart Failure Clinical Research Network has begun the Diuretics Optimization Strategies Evaluation (DOSE) study, a multi-center, double-blind, randomized controlled trial that will enroll 300 patients with ADHF. The DOSE study will randomize patients using a 2 × 2 factorial design to low dose vs. high dose furosemide, and intermittent bolus vs. continuous infusion. Successful completion of the DOSE study will provide important data on the optimal clinical use of loop diuretics in ADHF.

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Developed with the special contribution of the Heart Failure Association (HFA) of the ESC.

To review the clinical pharmacology of torsemide and to compare it with currently available loop diuretics, particularly furosemide. An English-language MEDLINE search, 1985 to October 1994, was used to identify pertinent literature, including review articles. Data from scientific literature were extracted, evaluated, and summarized for presentation. Pivotal and representative studies are discussed relating to the pharmacology, pharmacokinetics, and use of torsemide in patients with congestive heart failure, renal disease, hepatic disease, and hypertension. Torsemide is a loop diuretic of the pyridine-sulfonylurea class. The bioavailability of torsemide is approximately 80%, with little first-pass metabolism, and torsemide can be given without regard to meals. The serum concentration reaches its peak within 1 hour after oral administration and diuresis lasts approximately 6-8 hours. Torsemide is eliminated both hepatically (80%) and renally (20%) as unchanged drug with an elimination half-life of about 3.5 hours. Because of the high bioavailability, oral and intravenous doses are therapeutically equivalent. Torsemide, and other loop diuretics such as furosemide, are indicated for the treatment of edema associated with congestive heart failure, renal disease, and hepatic disease. They also are indicated for the treatment of hypertension alone or in combination with other antihypertensive agents. Depending on the indication, the recommended initial adult dosage of torsemide is between 5 and 20 mg once daily orally or intravenously. Special dosage adjustments in the elderly are not necessary. Torsemide is a loop diuretic similar to furosemide, with similar indications. Torsemide is characterized by good bioavailability and once-daily dosing and, compared with furosemide, provides generally equivalent therapeutic efficacy.

Background The importance of cardiorenal syndromes (CRS) in patients with heart failure has been shown in many studies. However, there is little data on the impact of a combination of heart failure and renal disease in patients with acute myocardial infarctions. Aim of the present study was to investigate, how often a combination of heart failure (HF) and kidney disease (KD) could be detected in patients with ST-elevation myocardial infarctions and to estimate its impact on outcome. Methods All patients from a German heart center, admitted with STEMI between 2006 and 2022 were analysed. CRS was defined as a combination of heart failure (HF: left ventricular ejection fraction (LV-EF<40%), HF) and kidney disease (KD: GFR at admission <60 ml/min). Patients were assigned in a 2x2 model: HF-/KD-, HF-/KD+, HF+/KD-, HF+/KD+. Outcome analysis was adjusted by confounders in a multivariate Cox-regression-model. Acute kidney injury (AKI) was calculated by AKIN-criteria (KDIGO) Results Of a total of 8276 STEMI-patients included in the study 5696(69%) had a preserved LV-EF and no KD (HF-/KD-), 1354 (16%) a preserved LV-EF and KD (HF-/KD+), 743 (9%) a reduced LV-EF and no KD (HF+/KD-) and 483 (6%) both a reduced LV-EF and KD (HF+/KD+, CRS-Group). In the CRS-group patients were on average older (74.2±12 yrs. vs. 60.8±13 yrs., p<0.01), more likely to be female (36.9% vs. 23.1% in the control group, p<0.01) and more likely to be diabetics (31.0% vs. 16.8% in the control group, p<0.01). CRS was associated with higher rates of cardiogenic shock (41.5% vs. 8.7% in the control group) and higher rates of subsequent AKI with a 18x higher risk to develop AKIN-3 with or without the need for renal replacement therapy (RRT), (table, upper part). In patients with CRS in 11% of patients a temporal RRT was necessary vs. 0.5% in controls. Furthermore, in CRS-patients in-hospital and 1 year-mortality-rates were markedly higher (table, lower part). When adjusting outcomes for confounders (age, gender, CS, diabetes, anterior STEMI, 3 VD) the detrimental effect of CRS on outcome remained: AKIN-3/RRT: OR 16.5, 95% CI 7.5-30.0, p<0.01, In-hospital-mortality: OR 14.2, 95% CI 7.8-21, p<0.01, 1-year-mortality: HR 10.5, 95% CI 7.5-14.1, p<0.01. Conclusions In this analysis of registry data, cardiorenal disease could be detected in 6% of STEMI-patients, with higher rates in women and in diabetics. Patients with cardiorenal disease showed a more than 18-fold higher risk of suffering severe renal failure during the index event and a 24-fold higher risk of in-hospital death. Patients with either heart failure or renal disease were situated between the CRS and control group with regard to outcome. These results underline the additive effects of cardiac and renal disease.Table:Event rates by HF and KD group

Introduction Torsemide is a loop diuretic that inhibits the Na+/K+/2Cl− cotransporter type 2 in the thick ascending loop of Henle, leading to increased excretion of urinary sodium and chloride and associated diuresis. While furosemide remains the dominant diuretic utilized in current practice, increasing evidence supports potential advantages of torsemide in heart failure (HF) and/or renal disease. Areas covered This narrative review covers the evidence for use of torsemide in HF and renal disease. Comparative effectiveness with regards to clinical outcomes is reviewed, as well as the ongoing multicenter trial, TRANSFORM-HF, comparing the effect of torsemide versus furosemide among patients with HF. Expert opinion Compared with furosemide, torsemide has favorable pharmacodynamics/pharmacokinetics including higher bioavailability, longer duration of effect, minor renal excretion, decreased kaliuresis, and enhanced natriuresis/diuresis. These properties may be further supported by differential effects on RAAS regulation and fibrosis modulation as compared with other diuretics. The limited current body of evidence indicates that torsemide may be superior to furosemide with respect to improving HF functional status and reducing HF hospitalization, and there are mixed data regarding effect on reducing overall cardiovascular hospitalizations/mortality. Further, randomized data are necessary to definitively determine if torsemide can reduce risk of mortality and hospitalization among patients with HF.

Excerpt The nephrotic syndrome is associated with a number of disease processes, which produce a variety of pathologic lesions in the kidney. The histology of many of these disease processes, inclu...

Symptomatic generalized toxoplasmosis is uncommon in an immunocompetent host. Even more unusual is the association of nephrotic syndrome with toxoplasmosis, which has previously been reported only in congenital or pediatric cases. This is the first reported case of generalized toxoplasmosis with nephrotic syndrome in an immunocompetent adult. This case should serve to alert the clinician to the possibility of toxoplasmosis in the diagnosis of FUO and adult nephrotic syndrome, and it demonstrates resolution without antimicrobial agents.

Deferasirox Is Associated with Reduced Mortality Risk in a Medicare Population with Myelodysplastic Syndromes

Background: Amyloidosis is the deposition of abnormal localized or systemic extracellular proteins in tissues. Upper and lower gastrointestinal (GI) bleeds are a known complication of amyloidosis. We assess risk factors and outcomes associated with GI bleeding in hospitalized patients with amyloidosis. Methods: This retrospective study used data from the 2015-2018 National Inpatient Sample Database to determine the prevalence of GI bleeding and risk factors associated with GI bleeding in patients with amyloidosis based on ICD-9 codes. Demographics included age, race, and gender. Comorbidities included hypertension, diabetes, heart failure, renal failure and coronary artery disease. Outcomes included death, and length of stay (LOS). The weight adjusted prevalence of GI bleed was estimated using binomial model with 95% confidence interval (CI) and the association was summarized with weighted relative risk (RR) regression analyses. Results: This study included 34,894 records of patients with amyloidosis, of which 1,022 had GI bleed. Amyloidosis patients with GI bleeds were older than patients without GI bleeds (63.86 vs. 60.94 years, p= <.0001 and more likely to be male (51.85 vs. 42.04 p= <.0001) and had more renal failure, diabetes, heart failure, and liver disease. Amyloidosis patients with GI bleed had significantly higher length of stay (2.93 [95% CI 2.75-3.12]) and higher mortality than those without GI bleeding (RR 2.64 [95% CI 2.17 - 3.22], p <0.0001). Conclusion: Among patients with amyloidosis, GI bleeding was more common in males, older individuals, and those with renal failure, diabetes, heart failure, and liver disease. Patients with amyloidosis and GI bleeds had significantly higher mortality with longer LOS than those without GI bleeding. Patients with amyloidosis with GI bleeding should be targeted for aggressive therapies to improve outcomes.