Protocolized Diuretic Strategy as a Treatment Algorithm for Cardiorenal Syndrome

Abstract

Background: A diuretic strategy is needed that is superior to current clinical care in the management of cardiorenal syndrome. Current HF guidelines do not provide any standard protocol for diuretic dosing. Aim: To determine if a protocolized diuretic treatment strategy (ProDiuS), compared to usual care (UC), results in improved decongestion, clinical outcomes, and health-related quality of life (HRQOL), while preserving renal function in hospitalized patients with cardiorenal syndrome. Materials and Methods: This trial was a prospective randomized single-blind trial of participants hospitalized for cardiorenal syndrome from November 1, 2013 to July 9, 2015. Participants were randomized to ProDiuS vs. UC and followed daily in hospital, and at 1-month and 3-month follow-up. ProDiuS was a stepped diuretic strategy targeting daily urine output of 3-5 L/day. UC was care at the discretion of treating providers. The primary outcome, change in body weight (kg) from randomization to 96 hours (day 4), was compared between the ProDiuS and UC groups using the t-test. Data analysis for secondary outcomes between the two groups were conducted using the t-test or Wilcoxon rank sum test depending on whether data was skewed for continuous variables, as well as linear regression modeling. For ordinal variables or proportions, data were analyzed using the exact chi-square test and logistic regression modeling. For mortality, time to death was analyzed as time-to-event data, with censoring at the time of death, date of last follow-up, or the end of the study (3 month follow-up), using Kaplan-Meier curves and log-rank tests, and Cox proportional hazards models to adjust for continuous and discrete covariates in the survival analysis. Results: The study did not enroll the prespecified number of subjects due to slow recruitment. Out of 786 prescreened patients, 19 participants were included in the trial. There were no significant differences in baseline characteristics. Mean age was 68.7±7.3 years and 72.2% were male. There was borderline higher change in body weight from baseline to day 4 or discharge in ProDiuS vs. UC (-6.12 vs. -2.07 kg; p=0.05). Net negative fluid balance, length of hospitalization, HF rehospitalizations, mortality, acute kidney injury, adverse outcomes, and HRQOL scores were similar between groups. Conclusion: Due to small sample size, firm conclusions cannot be drawn. However, these findings suggest that ProDiuS results in similar clinical and HRQOL outcomes as UC in HF patients treated at a large tertiary medical center in the short term. This trial was conducted in an advanced HF population on specialized HF services, which may have attenuated the efficacy of ProDiuS vs. UC. Further studies with larger sample size and more diverse HF populations are needed to determine the efficacy and safety of ProDiuS. Several lessons learned in attempting to design a trial of protocolized diuretic strategy in the cardiorenal population are discussed.