Administration Of Diuretics Research Articles

Diuretic Renal Scintigraphy: The State of Practice and a Potential Opportunity for Standardization.

The aim of this study was to assess variation in diuretic renal scintigraphy (DRS) practice patterns and quantify compliance with the national guidance in a large cohort of laboratories from different institutions and practice settings across the United States. By means of an institutional review board-approved protocol, we extracted 107 facility-specific, adult DRS protocols and associated 174 reports from the Intersocietal Accreditation Commission database, representing all laboratories applying for genitourinary scintigraphy certification during the 2016 to 2018 accreditation cycle. From these, we assessed 40 variables regarding facilities and staffing, patient preparation, examination technique and acquisition, image processing, and reporting. Review of protocols and reports demonstrates a very high degree of variability in DRS practice across the United States and suboptimal compliance with societal guidelines and practice parameters. Some of the more variable or underreported parameters include the use of patient hydration, type and dosage of radiopharmaceutical, dosage and timing of diuretic administration, quantitative parameters assessed, and report content. There is high variability in the performance and reporting of DRS among laboratories applying for accreditation, similar to that seen in studies of other nuclear medicine examinations. The wide degree of practice variance may have a significant impact on diagnostic accuracy and patient management, with inaccurate or incomplete results. This survey impresses the need for standardization and improved quality of this important nuclear medicine examination.

FGF-23 (Fibroblast Growth Factor-23) and Cardiorenal Interactions

Animal models implicate FGF-23 (fibroblast growth factor-23) as a direct contributor to adverse cardiorenal interactions such as sodium avidity, diuretic resistance, and neurohormonal activation, but this has not been conclusively demonstrated in humans. Therefore, we aimed to evaluate whether FGF-23 is associated with parameters of cardiorenal dysfunction in humans with heart failure, independent of confounding factors. One hundred ninety-nine outpatients with heart failure undergoing diuretic treatment at the Yale Transitional Care Center were enrolled and underwent blood collection, and urine sampling before and after diuretics. FGF-23 was associated with several metrics of disease severity such as higher home loop diuretic dose and NT-proBNP (N-terminal pro-B-type natriuretic peptide), and lower estimated glomerular filtration rate, serum chloride, and serum albumin. Multivariable analysis demonstrated no statistically significant association between FGF-23 and sodium avidity measured by fractional excretion of sodium, or proximal or distal tubular sodium reabsorption, either before diuretic administration or at peak diuresis (P≥0.11 for all). Likewise, FGF-23 was not independently associated with parameters of diuretic resistance (diuretic excretion, cumulative urine and sodium output, and loop diuretic efficiency [P≥0.33 for all]) or neurohormonal activation (plasma or urine renin [P≥0.36 for all]). Moreover, the upper boundary of the 95% CI of all the partial correlations were ≤0.30, supporting the lack of meaningful correlations. FGF-23 was not associated with mortality in multivariable analysis (P=0.44). FGF-23 was not meaningfully associated with any cardiorenal parameter in patients with heart failure. While our methods cannot rule out a small effect, FGF-23 is unlikely to be a primary driver of cardiorenal interactions.

Temporal changes in resting heart rate before and after heart failure decompensation in a large real-world population of patients with reduced ejection fraction

Abstract Background Diagnostic parameters measured in implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy defibrillators (CRTD) have been shown to change before and after heart failure (HF) events with fluid overload. Purpose We investigated the temporal characteristics of nighttime heart rate, as a surrogate of resting heart rate, before and after HF events in a large real-world cohort of patients with ICD/CRTD devices. Methods We linked a de-identified database of aggregated electronic health record (EHR) data (2007–2017) to a manufacturer's device database with continuous diagnostic monitoring data. Patients with ICD/CRTD implants with HF related diagnostics were included for this study. The device computes nighttime heart rate as the average heart rate between midnight and 4 am. HF event was defined as an inpatient, emergency department, or observation unit stay in a hospital with primary diagnosis of HF and intravenous diuretics administration. Temporal ensemble average of night heart rate in the 60 days pre and post HF events were compared between HF events with and without readmission within 60 days as well as with periods with no HF events. Results A total of 17,886 patients with 1.8±1.2 years of follow-up met inclusion criteria. The average age of patients was 66.6±12.3 years, with 72% being males, and 51% with ICD devices. The average night heart rate pre and post HF events with and without readmission and in follow-ups with no events is shown in Figure. A total of 1174 patients had 1425 HF events with no readmission for HF within 60 days and 282 patients had 295 HF events which were followed by readmission for HF within 60 days. A total of 17,839 patients had no HF events over 86,858 follow-up months. A 3-day average night heart rate increased by >3 bpm in a large proportion of patients in the 30-day period before HF event compared to 30-day periods with no events (28% vs 16%; Odds Ratio: 2.08; p<0.001). Patients who were readmitted for HF have higher average NHR before and after admission compared to patients who are not readmitted. In patients who were not readmitted, the night heart rate recovers to baseline levels on an average within 10 days post discharge. Conclusions In a large real-world population of patients with ICD/CRTD devices, the average night heart rate increases before HF events. Patients who are readmitted are more likely to have higher night heart rate after discharge. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic Plc

Temporal characteristics of duration of daily activity before and after heart failure hospitalizations in a large real-world population of patients with cardiovascular implanted electronic devices

Abstract Background Diagnostic parameters measured in implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy defibrillators (CRTD) have been shown to change before and after heart failure (HF) events with fluid overload. Purpose We investigated the temporal characteristics of device measured daily activity duration before and after HF events in a large real-world cohort of patients with ICD/CRTD devices. Methods We linked a de-identified database of aggregated electronic health record (EHR) data (2007–2017) to a manufacturer's device database with continuous diagnostic monitoring data. Patients with ICD/CRTD implants with HF diagnostic feature were included for this study. Device accumulates the total number of active minutes during a 24-hour period with an active minute defined as total number of accelerometer fluctuations reaching a threshold during the minute. HF event was defined as an inpatient, emergency department, or observation unit stay in a hospital with primary diagnosis of HF and intravenous diuretics administration. Temporal ensemble average of daily duration of activity in the 60 days pre and post HF events were compared between HF events with and without readmission within 60 days and with periods with no HF events during follow-up. Results A total of 17,886 patients with 1.8±1.2 years of follow-up met inclusion criteria. The average age of patients was 66.6±12.3 years, with 72% being males, and 51% with ICD devices. The average daily duration of activity in HF events with and without readmission and with no events is shown in Figure. A total of 1174 patients had 1425 HF events with no readmission for HF within 60 days and 282 patients had 295 HF events which were followed by readmission for HF within 60 days. A total of 17,839 patients had no HF events over 86,858 follow-up months. The 7-day average activity duration decreased by >10 minutes in a large proportion of patients in the 30-day period before HF event compared to 30-day periods with no events (43% vs 34%; Odds Ratio: 1.52; p<0.001). A 7-day average activity duration increase of >10 minutes from admission to 30 days after admission happens in a smaller proportion of HF events with versus without HF readmission within 60 days of index admission (24% vs 31%; Odds Ratio: 0.7; p<0.001). Conclusions In a large real-world population of patients with ICD/CRTD devices, the average daily activity duration reduces before HF events. Re-admissions are more likely in patients with smaller increase in activity duration post discharge. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Medtronic Plc

Pulmonary arterial hypertension or heart failure with preserved ejection fraction? Beyond heart catheterization: a roadmap for challenging cases

The cause of dyspnea may remain uncertain even after a complete non-invasive clinical workup, and a right heart catheterization is performed to achieve a definitive diagnosis. Although pulmonary artery wedge pressure (PAWP) is key for the differential diagnosis between pulmonary arterial hypertension (PAH) and heart failure with preserved ejection fraction (HFpEF), the diagnosis may be challenging because PAWP may be normal after diuretic administration in HFpEF patients on optimal medical therapy. In order to avoid misdiagnosis, building a pre-test probability of pre- or post-capillary pulmonary hypertension is crucial. Current guidelines on pulmonary hypertension suggest to interpret hemodynamics in the context of clinical picture and imaging, mainly echocardiography. Indecisive measurements of PAWP in patients with an intermediate to high clinical probability of HFpEF can be repeated after a fluid challenge test with rapid infusion of 7 ml/kg or 500 ml of saline. The procedure is simple and does not take much catheterization laboratory time. A post-fluid challenge PAWP >18 mmHg strongly supports the diagnosis of occult HFpEF. A possible alternative to fluid challenge test is exercise or dobutamine stress test. However, exercise hemodynamics is not feasible in all catheterization laboratories and may be difficult to interpret due to wide swings in intrathoracic pressures. Otherwise, dobutamine infusion during right heart catheterization may be potentially more practical than exercise stress, but requires further validation studies to determine its utility. The aim of this case report is to provide a practical roadmap for challenging cases, when the differential diagnosis between PAH and HFpEF is uncertain.

HYPERKALEMIA CAUSING SEVERE MUSCLE WEAKNESS IN A PATIENT WITH RENAL INSUFFICIENCY

In individuals with renal insufficiency, hyperkalaemia is one of the most common electrolyte imbalances, whereas it is uncommon in healthy people. When potassium is given or combined with a potassium-sparing diuretic, it happens quickly. It usually does not produce any signs and symptoms and is identified with normal blood investigations. Hyperkalemia causes faulty heart conduction and muscle weakness, among other symptoms. Muscle weakness as a clinical manifestation, on the other hand, is infrequent in clinical practise. This could be due to the fact that cardiac symptoms frequently appear earlier than weakness of muscles, necessitating the implementation of suitable interventions even before potassium concentration reaches a level that causes weakness. We present a case in which a patient with renal insufficiency had acute weakness of muscles as a result of extreme hyperkalaemia that acquired fast recovery after potassium and potassium-sparing diuretic administration.

Epidemiology and Outcomes of Critically Ill Children at Risk for Pediatric Acute Respiratory Distress Syndrome: A Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology Study.

Interventional trials aimed at pediatric acute respiratory distress syndrome prevention require accurate identification of high-risk patients. In this study, we aimed to characterize the frequency and outcomes of children meeting "at risk for pediatric acute respiratory distress syndrome" criteria as defined by the Pediatric Acute Lung Injury Consensus Conference. Planned substudy of the prospective multicenter, international Pediatric Acute Respiratory Distress Syndrome Incidence and Epidemiology study conducted during 10 nonconsecutive weeks (May 2016-June 2017). Thirty-seven international PICUs. Three-hundred ten critically ill children meeting Pediatric Acute Lung Injury Consensus Conference "at-risk for pediatric acute respiratory distress syndrome" criteria. None. We evaluated the frequency of children at risk for pediatric acute respiratory distress syndrome and rate of subsequent pediatric acute respiratory distress syndrome diagnosis and used multivariable logistic regression to identify factors associated with subsequent pediatric acute respiratory distress syndrome. Frequency of at risk for pediatric acute respiratory distress syndrome was 3.8% (95% CI, 3.4-5.2%) among the 8,122 critically ill children who were screened and 5.8% (95% CI, 5.2-6.4%) among the 5,334 screened children on positive pressure ventilation or high-flow oxygen. Among the 310 at-risk children, median age was 2.1 years (interquartile range, 0.5-7.3 yr). Sixty-six children (21.3%) were subsequently diagnosed with pediatric acute respiratory distress syndrome, a median of 22.6 hours (interquartile range, 9.8-41.0 hr) later. Subsequent pediatric acute respiratory distress syndrome was associated with increased mortality (21.2% vs 3.3%; p < 0.001) and longer durations of invasive ventilation and PICU care. Subsequent pediatric acute respiratory distress syndrome rate did not differ by respiratory support modality at the time of meeting at risk criteria but was independently associated with lower initial saturation:Fio2 ratio, progressive tachycardia, and early diuretic administration. The Pediatric Acute Lung Injury Consensus Conference "at-risk for pediatric acute respiratory distress syndrome" criteria identify critically ill children at high risk of pediatric acute respiratory distress syndrome and poor outcomes. Interventional trials aimed at pediatric acute respiratory distress syndrome prevention should target patients early in their illness course and include patients on high-flow oxygen and positive pressure ventilation.

Compensatory post-diuretic renal sodium reabsorption is not a dominant mechanism of diuretic resistance in acute heart failure.

In healthy volunteers, the kidney deploys compensatory post-diuretic sodium reabsorption (CPDSR) following loop diuretic-induced natriuresis, minimizing sodium excretion and producing a neutral sodium balance. CPDSR is extrapolated to non-euvolemic populations as a diuretic resistance mechanism; however, its importance in acute decompensated heart failure (ADHF) is unknown. Patients with ADHF in the Mechanisms of Diuretic Resistance cohort receiving intravenous loop diuretics (462 administrations in 285 patients) underwent supervised urine collections entailing an immediate pre-diuretic spot urine sample, then 6-h (diuretic-induced natriuresis period) and 18-h (post-diuretic period) urine collections. The average spot urine sodium concentration immediately prior to diuretic administration [median 15 h (13-17) after last diuretic] was 64 ± 33 mmol/L with only 4% of patients having low (<20 mmol/L) urine sodium consistent with CPDSR. Paradoxically, greater 6-h diuretic-induced natriuresis was associated with larger 18-h post-diuretic spontaneous natriuresis (r = 0.7, P < 0.001). Higher pre-diuretic urine sodium to creatinine ratio (r = 0.37, P < 0.001) was the strongest predictor of post-diuretic spontaneous natriuresis. In a subgroup of patients (n = 43) randomized to protocol-driven intensified diuretic therapies, the mean diuretic-induced natriuresis increased three-fold. In contrast to the substantial decrease in spontaneous natriuresis predicted by CPDSR, no change in post-diuretic spontaneous natriuresis was observed (P = 0.47). On a population level, CPDSR was not an important driver of diuretic resistance in hypervolemic ADHF. Contrary to CPDSR, a greater diuretic-induced natriuresis predicted a larger post-diuretic spontaneous natriuresis. Basal sodium avidity, rather than diuretic-induced CPDSR, appears to be the predominant determinate of both diuretic-induced and post-diuretic natriuresis in hypervolemic ADHF.

PD45-12 INTRAOPERATIVE MANNITOL ADMINISTRATION DURING LAPAROSCOPIC DONOR NEPHRECTOMY AND IMPACT ON LONG-TERM GRAFT FUNCTION

You have accessJournal of UrologyRenal Transplantation & Vascular Surgery II (PD45)1 Sep 2021PD45-12 INTRAOPERATIVE MANNITOL ADMINISTRATION DURING LAPAROSCOPIC DONOR NEPHRECTOMY AND IMPACT ON LONG-TERM GRAFT FUNCTION Gustavo Gryzinski, Jason Farrow, Clinton Bahler, and Chandru Sundaram Gustavo GryzinskiGustavo Gryzinski More articles by this author , Jason FarrowJason Farrow More articles by this author , Clinton BahlerClinton Bahler More articles by this author , and Chandru SundaramChandru Sundaram More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002059.12AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: End-stage renal disease frequently results in dialysis, and at best, transplantation. Laparoscopic donor nephrectomy was introduced in 1995 and has been a valuable source of high-quality organs. Improving long-term graft function of recipients through judicious intraoperative medical management remains an essential goal. Infusion of mannitol prior to hilar clamping during donor nephrectomy has been utilized based on its proposed cytoprotective properties – theoretically improving renal perfusion, free-radical scavenging, and diuresis. However, there is a paucity of large, long-term studies evaluating its use. In this study, we aimed to explore the long-term effects of intraoperative mannitol administration on graft function as measured by creatinine. METHODS: A single-center, retrospective analysis of a contemporary cohort of donor nephrectomies was performed. Eighty donors (sample determined using a power of 0.8 to detect a 20% difference in creatinine) were identified and then matched to recipients using Indiana University’s Organ Transplant Tracking Record database. Patients were balanced by sex and stratified by intraoperative administration of mannitol (yes vs no). Creatinine was recorded at fixed intervals per routine nephrology follow-up. Statistical analysis was performed using SPSS. RESULTS: Basic demographics are presented in Table 1. The only significant difference in baseline clinical factors was donor intraoperative diuretic administration, which was more frequently co-administered with mannitol. Creatinine means by time can be seen in Figure 1. Multiple means comparisons were made using ANOVA and did not reveal any differences in creatinine at three years post-transplant (p > 0.05). CONCLUSIONS: Mannitol administration did not statistically affect post-transplant creatinine up to the three-year follow-up. On post-hoc analysis, elimination of cases where diuretics were co-administered did not change these results. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e746-e747 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Gustavo Gryzinski More articles by this author Jason Farrow More articles by this author Clinton Bahler More articles by this author Chandru Sundaram More articles by this author Expand All Advertisement Loading ...

Predictive Factors of 30-day Adverse Events in Acute Heart Failure after Discharge from Emergency Department; a Historical Cohort Study.

Introduction:The rates of unscheduled emergency department (ED) visits and readmissions after discharge from the ED in acute heart failure (AHF) patients are high. This study aimed to identify the predictive factors of 30-day adverse events after discharge from the ED. Methods: A retrospective study was conducted from 2017 to 2019 in patients diagnosed with AHF and discharged from the ED at a tertiary university hospital. Thirty-day adverse events were defined as (i) unscheduled revisit to the ED with AHF, (ii) hospital admission from AHF, and, (iii) death after discharge from the ED. The predictive factors of 30-day adverse events were examined using multivariate analyses by logistic regression. Results:421 patients with the median age of 73 (IQR: 63-81) years were studied (52.3% male). 81 (19.2%) patients had 30-day adverse events. Significant predictive factors of 30-day adverse events consisted of underlying valvular heart disease (OR = 2.46; 95%CI: 1.27-4.78; p = 0.008), chronic obstructive pulmonary disease (COPD) (OR = 0.08; 95%CI: 0.01-0.64; p=0.001), malignancy (OR=3.63; 95%CI: 1.17-11.24; p = 0.031), New York Heart Association functional class III (OR = 4.88; 95%CI: 0.93-25.59) and IV (OR = 7.23; 95% CI: 1.37-38.08) at the ED (p = 0.035), and serum sodium <135 mmol/L (OR = 2.20; 95%CI: 1.17-4.14; p = 0.014). Precipitating factors were anemia (OR = 2.42; 95%CI: 1.16-5.02; p = 0.021), progressive valvular heart disease (OR = 3.52; 95%CI: 1.35-7.85; p = 0.009), acute kidney injury (OR = 6.98; 95%CI: 2.32-20.96; p < 0.001), time to diuretic administration >60 minutes after ED arrival (OR = 3.89; 95%CI: 2.16-7.00; p < 0.001), and no discharge advice for follow-up (OR = 2.30; 95%CI: 1.10-4.77; p = 0.028). Conclusion:AHF patients who had good response to intravenous diuretics and were discharged from the ED were at high risk for 30-day adverse events. Ten factors predicted 30-day adverse events after discharge from the ED.

Outcomes of women with congenital heart disease admitted to acute-care hospitals for delivery in Japan: a retrospective cohort study using nationwide Japanese diagnosis procedure combination database

BackgroundThe number of women with congenital heart disease (CHD) who are of childbearing age is increasing due to advancements in medical management. Nonetheless, data on the outcomes of delivery in women with CHD remain limited. Therefore, we conducted a retrospective cohort study using a nationwide database of deliveries by women with CHD.MethodsDeliveries by women with CHD discharged from acute-care hospitals between April 2017 and March 2018 were identified based on the Diagnosis Procedure Combination database which covers almost all acute-care hospitals in Japan. By using this database, we tried to include relatively high-risk deliveries by women with CHD. Subjects were divided into three groups according to the underlying disease complexity: simple, moderate, and great complexity. The clinical characteristics and incidence of peripartum cardiovascular events were compared among the three groups.ResultsA total of 249 deliveries from 107 hospitals were included. The largest facility had 29 deliveries per year. Given the uncertainty of underlying cardiac anomalies, 48 women were excluded, and the remaining 201 women (median age, 32 years) were analyzed. In-hospital maternal death, use of extracorporeal membrane oxygenation, intra-aortic balloon pump, pacemaker, and direct current cardioversion were not observed. Nine patients (4.5%) required intravenous diuretic administration. However, the difference in the frequency of diuretic use was not significant among the three groups (simple, 1.9%; moderate, 7.2%; great, 6.9%; P = 0.204). One participant required valve replacement surgery at 22 days after a successful cesarean section. As the disease complexity increased, deliveries occurred more frequently at university hospitals (simple, 41.7%; moderate, 52.2%; great, 72.4%; P = 0.013) and the length of hospitalization was significantly longer, with median durations of 9.0 (interquartile range [IQR] 7.0–11.0) days, 10.0 (IQR 8.0–24.0) days, and 11.0 (IQR 8.0–36.0) days in the simple, moderate, and great complexity groups, respectively (P = 0.002).ConclusionsAppropriate patient selection and management by specialized tertiary institutions may contribute to positive outcomes in pregnancies in women with CHD.

Parapelvic cyst: A rare cause of ureteropelvic junction obstruction in a pediatric patient managed with robotic cyst decortication

We report a case of a right parapelvic renal cyst causing intermittent ureteropelvic junction obstruction (UPJO). A 13-year-old male was referred for right flank pain. Stone protocol CT revealed renal pelvis dilation with punctate stones. Due to concern for intermittently obstructive calculi, he underwent ureteroscopy, which was unremarkable. A diuretic renogram showed symmetric uptake with partial emptying on the right with pain after diuretic administration. In office, we potentiated a Dietl's crisis with ultrasound obtained before and after fluid intake. Comparison of ultrasounds revealed a parapelvic cyst causing calyceal dilation. He was counseled for robotic cyst decortication and possible pyeloplasty. A robotic cyst decortication was performed. Once decorticated, the cyst base was fulgurated and pararenal fat was interposed into the cyst base. Console time was 70min with minimal blood loss. The patient was discharged post-operative day 1. Follow-up renal ultrasound at 4 months demonstrated resolution of hydronephrosis and parapelvic cyst. Parapelvic renal cysts causing intermittent UPJO is a rare entity that may be missed on a diuretic renogram. Clinical suspicion and appropriate imaging with ultrasound or magnetic resonance imaging are useful. Robotic cyst decortication is a technically feasible approach to treat this condition.

Multiple myeloma-associated light chain amyloidosis involving heart, kidneys, and peripheral nerves

Abstract Introduction: Multiple myeloma (MM) is a hematologic malignancy characterized by the clonal proliferation of monoclonal protein-producing plasma cells and can cause immunoglobulin light chain (AL) amyloidosis. Although MM-associated AL amyloidosis is rare, it can significantly increase patient mortality, as its various non-specific symptoms can delay diagnosis and treatment. Patient concerns: A 77-year-old female patient visited a renal clinic with complaints of generalized edema and dyspnea (New York Heart Association class III) persisting for three weeks. The patient had hypoalbuminemia, mild anemia, and nephrotic-range proteinuria. Echocardiography revealed concentric hypertrophy of the left ventricle and sparkling textures in the myocardium. Serum protein immunofixation revealed monoclonal gammopathy of immunoglobulin G/lambda light chain. A bone marrow biopsy showed 30% plasmacytosis scattered with cluster of differentiation 138-positive plasma cells. A kidney biopsy demonstrated a mesangial matrix positive for Congo red staining and deposition of amyloid fibrils on electron microscopy. Sensorimotor polyneuropathy was noted on the nerve conduction studies of both lower extremities. Diagnosis: The patient was diagnosed with heart failure, nephrotic syndrome, and peripheral neuropathy caused by MM-associated AL amyloidosis. Interventions: She was given supportive treatment upon admission, including administration of diuretics, albumin, and vasopressors, followed by combination chemotherapy (melphalan and dexamethasone). Outcomes: The patient's condition deteriorated due to heart failure and azotemia. She died from multiple organ failure on the 28th day of hospitalization. Conclusion: MM-associated AL amyloidosis can rapidly progress to fatal multiple organ failure. Therefore, if AL amyloidosis is suspected in patients with MM, prompt assessment of organ dysfunction and early initiation of intensive care including proper chemotherapy are required.

Comparative study of intravenous diuretics therapy-bolus versus infusion regimen in acute decompensated heart failure

Background: Heart failure (HF) is a growing problem worldwide; more than 20 million people around the world are affected. The objective of the study was to compare the effect of different modes of administration of intravenous diuretic –bolus versus infusion, in acute decompensated heart failure in relation to diuresis and electrolyte balance.Methods: This prospective study was conducted in Darbhanga Medical College and hospital, Laheria sarai between October 2014 to November 2016. Patients of acute decompensated heart failure attending medical emergency ward and Intensive care unit of medicine department of Darbhanga Medical College and hospital, Laheria sarai were selected and grouped randomly as per inclusion and exclusion criteria.Results: The main findings of our study were greater diuresis in the first 24 h of admission with bolus dose. No difference in serum sodium or serum potassium levels between the groups.Conclusions: All three modes of diuretic therapies can be practiced with no difference in worsening of electrolyte levels. Bolus dose administration with its rapid volume loss might be a more effective diuretic strategy in our country with limited health resources.

Association of early administration of furosemide with improved oxygenation in patients with acute heart failure.

AimsOptimal pharmacological treatment for chronic heart failure has been established. However, treatments that can improve the prognosis of acute heart failure (AHF) are controversial. Although intravenous diuretics may be one optimal treatment option, little evidence has shown the effect of early administration of diuretics on clinical outcomes in patients with AHF. The aim of this study was to evaluate the association between door‐to‐furosemide (D2F) time, improved oxygenation, and in‐hospital mortality in patients hospitalized for AHF.Methods and resultsWe screened 494 patients hospitalized for AHF in Miyazaki Prefectural Nobeoka Hospital. AHF patients who were treated with intravenous furosemide within 24 h of arrival at the hospital were included in this study. D2F time was defined as the time from patient arrival at the hospital to the first intravenous dose of furosemide. The early administration group was defined as those with D2F time ≤60 min, whereas the non‐early group was defined as those with D2F time >60 min. The primary outcome was the rate of improved oxygenation at Day 1. The secondary outcomes were in‐hospital mortality and cardiac death.There were 219 patients treated with the first intravenous dose of furosemide within 24 h analysed after the exclusion of 275 patients. The median D2F time was 55 min (interquartile range: 30–120 min) in the final cohort. The early administration group included 121 patients (55.3%). The rate of improved oxygenation was higher in the early group than the non‐early group [median 16.7% (interquartile range: 0.0–40.0) vs. 0.0% (0.0–20.6), respectively, P < 0.001]. During the study period, there were six patients (5.0%) with in‐hospital mortality in the early group and nine patients (9.2%) in the non‐early group (P = 0.218). Cardiac death was observed less frequently in the early group than in the non‐early group, but without statistical significance (3.3% and 9.2%, respectively) (P = 0.067). The univariable logistic regression analyses showed that early administration of furosemide was associated with improved oxygenation [odds ratio (OR): 2.26; 95% confidence interval (CI): 1.31–3.91; P = 0.004], but not with in‐hospital mortality (OR: 0.52; 95% CI: 0.18–1.50; P = 0.225) or cardiac death (OR: 0.34; 95% CI: 0.10–1.13; P = 0.079). In multivariable analyses adjusted for risk score or relevant variables, early administration of furosemide was consistently associated with improvement of oxygenation.ConclusionsThe present study showed that in AHF patients, the early administration of furosemide was associated with improved oxygenation.

Optimization of ultrasonographic ureteral jet detection and normal ureteral jet morphology in dogs.

Ureteral jets are visualized with ultrasound as echogenic streams extending from the ureterovesicular junction into the urinary bladder. In clinical practice, diuretics are sometimes administered to increase visibility of ureteral jets, however this has not been well described in the veterinary literature. The purpose of this prospective, crossover study was to describe the normal morphology of canine ureteral jets, determine an optimal protocol for diuretic administration to increase visibility of ureteral jets, and confirm in vitro the effect that differences in specific gravity and velocity have on visibility. Ultrasound of 10 normal dogs was performed at baseline and following 1mg/kg furosemide administered intravenously or subcutaneously. Increased numbers of ureteral jets were seen post-furosemide administration compared to baseline, with an overall increased number of ureteral jets identified following intravenous administration when compared to subcutaneous administration. Time to first ureteral jet was significantly shorter with intravenous compared to subcutaneous administration. Urine specific gravity significantly decreased following furosemide administration. For the in vitro study, saline solutions of varying specific gravities were infused into a bath of hypertonic saline with specific gravity of 1.037. There was good visibility in vitro with infusion of solutions of specific gravities of 1.010-1.025. Infusion of saline solution with a specific gravity of 1.030 had reduced visibility, while infusion of saline with equivalent specific gravity (1.037) was not visible with B-mode ultrasonography. Both intravenous and subcutaneous furosemide administration significantly increase ureteral jet detection with ultrasound secondary to differences in specific gravity, confirming results of prior studies.

Early diuretic strategies and the association with In-hospital and Post-discharge outcomes in acute heart failure

Decongestion is a primary goal during hospitalizations for decompensated heart failure (HF). However, data surrounding the preferred route and strategy of diuretic administration are limited with varying results in prior studies. This is a retrospective analysis using patients from ASCEND-HF with a stable diuretic strategy in the first 24 hours following randomization. Patients were divided into three groups: intravenous (IV) continuous, IV bolus and oral strategy. Baseline characteristics, in-hospital outcomes, 30-day composite cardiovascular mortality or HF rehospitalization and 180-day all-cause mortality were compared across groups. Inverse propensity weighted modeling was used for adjustment. Among 5,738 patients with a stable diuretic regimen in the first 24 hours (80% of overall ASCEND trial), 3,944 (68.7%) patients received IV intermittent bolus administration of diuretics, 799 (13.9%) patients received IV continuous therapy and 995 (17.3%) patients with oral administration. Patients in the IV continuous group had a higher baseline creatinine (IV continuous 1.4 [1.1-1.7]; intermittent bolus 1.2 [1.0-1.6]; oral 1.2 [1.0-1.4] mg/dL; P <0.001) and high NTproBNP (IV continuous 5,216 [2,599-11,603]; intermittent bolus 4,944 [2,339-9,970]; oral 3,344 [1,570-7,077] pg/mL; P <0.001). There was no difference between IV continuous and intermittent bolus group in weight change, total urine output and change in renal function till 10 days/discharge (adjusted P >0.05 for all). There was no difference in 30 day mortality and HF readmission (adjusted OR 1.08 [95%CI: 0.74, 1.57]; P=0.701) and 180 days mortality (adjusted OR 1.04 [95%CI: 0.75, 1.43]; P=0.832). In a large cohort of patients with decompensated HF, there were no significant differences in diuretic-related in-hospital, or post-discharge outcomes between IV continuous and intermittent bolus administration. Tailoring appropriate diuretic strategy to different states of acute HF and congestion phenotypes needs to be further investigated.

Association between diuretic administration before diagnosis and incidence of acute kidney injury in patients with minimal change disease: A single-center observational study.

We examined the association between diuretic administration before the diagnosis of minimal change disease and the incidence of acute kidney injury. Moreover, we examined whether the use of diuretics affected the time to complete remission in adults with such disease.The present study was a single-center, retrospective, observational cohort study. We included 107 patients with biopsy-proven minimal change disease who were treated at a tertiary referral center in Japan between January 1, 2000 and March 31, 2019. All biopsy specimens were examined by a board-certified renal pathologist. The patients were considered to have minimal change disease when the kidney biopsy specimen had no glomerular lesions or only mild focal mesangial prominence (not exceeding 3 or 4 cells per segment) by light microscopy and/or foot process effacement by electron microscopy. Logistic regression and Kaplan–Meier curve analyses were performed, comparing the data of patients who received diuretics or not.The median age was 47 (28–66) years, 52% of patients were women, and the median proteinuria dosage was 8.3 (5.3–11.2) g/d. When minimal change disease was diagnosed, 27% of patients were taking diuretics. Within 30 days after the diagnosis, acute kidney injury occurred in 27% of patients. On multivariable logistic regression analysis, the use of diuretics was significantly associated with a higher risk of acute kidney injury. The use of diuretics was also associated with a longer time to complete remission.Diuretic administration can be associated with an elevated acute kidney injury risk and longer remission time in adult patients with newly diagnosed minimal change disease.

Generalized edema and heart failure caused from hypothyroidism and ferrous agent for hypochromic anemia

The patient was an 85-year-old female who has been treated for hypertension and atrial fibrillation (Af). She has visited outpatient clinic and has received regularly general blood tests for every six months. Hemoglobin (Hb) level was stable as 11.2-12.3 g/dL and MCV 88fL from 2017, but it decreased suddenly to 5.2 g/dL and 64 fL in Sept 2020. She did not feel any symptoms or signs. Further evaluations revealed that occult blood in stool and upper and endoscopic exams were negative. About 40 days after starting sodium ferrous citrate, she developed edema anasarca, bilateral pleural effusion and heart failure. Laboratory test showed hypothyroidism, and then the administration of thyroid hormone and diuretics brought her early improvement. As to this impressive case report, general clinical progress and some discussion of the relationship among anemia, edema anasarca, heart failure and hypothyroidism would be described.

Comparison between ultrafiltration and loop diuretics to neurohormonal and kidney parameters in cardiorenal syndrome type 1: a meta-analysis of randomized controlled trials

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Acute heart failure can affect the kidney, which is known as cardiorenal syndrome (CRS) type 1 that may worsen renal function and increase mortality. Ultrafiltration (UF) and loop diuretics are CRS type 1 treatment modalities mainly in improving congestion. Renin-angiotensin-aldosterone system (RAAS) is one of the key role mechanisms in type-1 CRS patients. Previous studies showed inconclusive neurohormonal and kidney parameters outcome comparisons between UF and loop diuretics in type-1 CRS patients. Purpose This study has the purpose to compare the effect of UF and loop diuretics to neurohormonal and renal parameters in type-1 CRS patients. Methods We did comprehensive searching using predefined keywords in online databases of Pubmed, ScienceDirect, EMBASE, and The Cochrane Library to screen all relevant literature until November 2020. We included all randomized controlled trials (RCTs) that compared the neurohormonal and renal parameters between UF and loop diuretics in type-1 CRS patients, not on chronic dialysis therapy and have serum creatinine (SCr) below 3 mg/dL. The neurohormonal parameters analysed in this study are changes of N-terminal pro-brain natriuretic peptide (NT-proBNP), plasma renin activity (PRA), and serum aldosterone, while the renal parameters analysed are changes of SCr, Cystatin-C, and dialysis dependency. We used Cochrane Risk-of-bias tools for accessing bias risk. We performed analysis to provide standard mean difference (SMD) for laboratory parameters and risk ratio (RR) for dialysis dependency with 95% confidence interval (CI) using fixed-effect heterogeneity test. Results We included 11 RCTs met our inclusion criteria. The UF groups showed more NT-proBNP decline compared with the diuretics groups although not statistically significant (SMD = -0.02, 95% CI -0.22 to 0.17, p = 0.80, I²=0%). The UF group showed RAAS activity increment, which are significantly difference in PRA (SMD = 0.38, 95% CI 0.12 to 0.63, p = 0.004, I²=54%) but no significance in aldosterone change (SMD = 0.09, 95% CI -0.17 to 0.34, p = 0.50, I²=0%). Surprisingly, the UF group tends to have incremental dialysis dependency risk although not statistically significant (pooled RR = 1.28, 95% CI 0.73 to 2.26, p = 0.39, I²=0%). The diuretics group shows more significant SCr improvement (SMD = 0.23, 95% CI 0.08 to 0.38, p = 0.003, I²=41%), yet no significance Cystatin-C improvement (SMD = 0.21, 95% CI -0.02 to 0.43, p = 0.07, I²=0%). Conclusions There is no significant difference between ultrafiltration and loop diuretics to neurohormonal and kidney parameters change in type-1 CRS patients although loop diuretics administration shows more benefits. However, further trials are needed to establish the comparison.