Diuresis In Patients Research Articles

Effects of Implementing a Heart Failure Order Set to Optimize Guideline-Directed Medical Therapy and Diuresis in Patients with Acute Heart Failure.

Background: Utilization of guideline-directed medical therapy in patients hospitalized for acute heart failure is suboptimal during the hospitalization and after discharge. An inpatient heart failure order set may be a convenient and useful intervention to improve heart failure therapy in the inpatient setting. Methods: This is a retrospective study that assessed the use of an inpatient heart failure order set on pharmacologic therapy in patients hospitalized for acute heart failure from May to August 2022. Patients with heart failure with an ejection fraction less than 50% were included in the analysis. The co-primary endpoints were maintenance or optimization of guideline-directed medical therapy during the hospitalization. Results: Maintenance of guideline-directed medical therapy was significantly greater when providers used the heart failure order set (OR 2.35, 95% CI 1.03-5.33, P = .041). Optimization of guideline-directed medical therapy was also statistically greater with use of the order set (OR 11.31, 95% CI 4.37-29.31, P < .001). Conclusions: An inpatient heart failure order set may be an effective strategy to improve heart failure pharmacotherapy in patients hospitalized with acute heart failure.

Эффективность алгоритма назначения диуретической терапии под контролем натрийуреза у пациентов с острой декомпенсацией сердечной недостаточности в отделении реанимации и интенсивной терапии: проспективное интервенционное контролируемое исследование

INTRODUCTION: The European Society of Cardiology suggests using early and repeated assessment of sodium content in urine in patients admitted with heart failure to evaluate diuretic therapy. OBJECTIVES: Evaluation of the effectiveness of the algorithm for diuretic therapy under the control of natriuresis in patients with acute decompensation of chronic heart failure (ADCHF) in the intensive care unit (ICU). MATERIALS AND METHODS: A prospective study included 150 patients hospitalized in the ICU with ADCHF. All patients underwent standard physical, laboratory and instrumental examinations. The starting dose of furosemide was 20 mg i/v. After 2 hours, a quantitative assessment of sodium in urine was performed. If the natriuresis was ≥ 70 mmol/l, furosemide was continued at the same dose every 12 hours. If the natriuresis was &lt; 70 mmol/L, the dose of furosemide was doubled. Natriuresis was monitored every 12 hours. RESULTS: In the natriuresis-controlled group the duration of patients' stay in the ICU was significantly shorter (3 vs. 5 days, p = 0.01), achieving euvolemia was significantly more frequent (42 % vs. 12 %, p &lt; 0.05), the daily diuresis in patients was significantly higher on more daily (120 mg vs. 80 mg, p &lt; 0.05) and the total dose of furosemide (420 mg vs. 240 mg, p &lt; 0.05). There was a pronounced decrease in congestion in the group of patients with natriuresis control with less pulmonary (number of B-lines 9.6 ± 1.2 versus 23.4 ± 2.5) and venous congestion (GRADE 0–56 %, 1–20 %, 2–24 %, 3–0 % against 0–20 %, 1–35 %, 2–18 %, 3–27 %) on the 3rd day of hospitalization. CONCLUSION: The inclusion of an algorithm for diuretic therapy under the control of natriuresis in patients with ADCHF in the ICU is effective and contributes to a more pronounced and rapid reduction of congestion, as well as a 1.5-fold reduction of time in the ICU.

Randomized trial assessing worsening renal function with dapagliflozin addition in acute decompensated heart failure: ROAD-ADHF trial

Abstract Background Dapagliflozin (DAPA), a sodium-glucose co-transporter 2 inhibitor, has shown to reduce cardiovascular mortality in patients with chronic heart failure.1) In addition, DAPA can enhance diuresis in patients with acute decompensated heart failure (ADHF).2) However, there is little known how early initiation of DAPA might impact the worsening renal function (WRF) when combined with standard decongestive therapy for ADHF. Purpose We aimed to evaluate the impact of initiating DAPA within 24 hours after ADHF admission on WRF, compared to standard decongestive therapy with loop diuretics alone. Methods We enrolled consecutive ADHF patients with a left ventricular ejection fraction (LVEF) less than 50%. The patients were prospectively randomized to either the DAPA group who received DAPA at a dose of 10 mg once daily within 24 hours of admission or the conventional therapy group (CON group) who received loop diuretics alone. Furosemide, loop diuretic, dosage was adjusted by increase or decrease of 10 mg to maintain urine output between a 1-2 mL/kg/hour.3) The primary endpoint was the incidence of WRF, which was defined as an increase in the serum creatinine of ≥ 0.3 mg/dL from baseline within 7 days of admission.4) Additionally, right heart catheterization (RHC) was performed before discharge if the consent was obtained. Results From May 2021 to May 2023, we analyzed a total of 114 patients (56 in the DAPA group and 58 in the CON group). The mean age was 73 years, 35% were female, and the mean LVEF was 32.5%. There was no significant difference in the incidence of WRF between two groups (16.1% in the DAPA group vs. 12.1% in the CON group, P=0.54, Figure 1). The cumulative loop diuretics dose over 7 days was lower in the DAPA group than CON group (184 ± 9.64 mg vs. 214 ± 9.81 mg, P=0.03, Figure 2). RHC before discharge was performed in 54 patients (96.4%) in the DAPA group and in 54 (93.1%) in the CON group. There were no significant differences in the pulmonary artery wedge pressure, pulmonary artery pressure, right atrial pressure, and cardiac index by the thermodilution method or the Fick method between two groups. Conclusion This randomized prospective trial revealed the early initiation of DAPA within 24 hours of admission for ADHF reduced loop diuretic demand without inducing WRF compared to standard decongestive therapy.Figure 1Figure 2

Spot urine sodium-to-creatinine ratio surpasses sodium in identifying poor diuretic response in acute heart failure.

We aim to identify the most accurate marker for early prediction of poor diuretic response in acute heart failure (AHF) patients with signs of congestion requiring intravenous diuretic treatment. In this single-centre, prospective observational study, AHF patients with signs of congestion received a standardized intravenous furosemide dose (1mg/kg of body weight; 40mg in bolus and remaining dose in 2h continuous infusion). Subsequently, we assessed spot urine composition at 2h post-administration, comparing it with total urine output at 6h. Various potential urine markers were analysed for predicting urine output using receiver operating characteristic (ROC) curves and logistic regression models. We investigated guideline-recommended markers, including spot urine sodium (UNa+) and its cut-off, and introduced the UNa+/UCr (urine creatinine concentration) ratio adjusting UNa+ for urine dilution. Out of 111 patients (85% males, 66.4±13.9years old, NTproBNP 7290 [4493-14582] pg/ml), there were 18 (16%) with a poor diuretic response (cumulative urine output <600ml during the first 6h). The mean 6h cumulative diuresis in patients with poor and good diuretic response was 406±142 and 2114±1164ml, respectively, P<0.005. After an initial evaluation of several potential biomarkers, only UNa+, UCr and UNa+/UCr were selected as candidates with the highest predictive value. The cut-off for UNa+ adjusted for urine dilution: UNa+/UCr ratio <0.167mmol/mg×10-1 was determined by ROC analysis with the highest area under the curve (95% confidence interval): 0.956 (0.915-0.997), P<0.001. When compared with the guideline-recommended cut-off (UNa+ <50mmol/L as a reference, specificity-0.97; sensitivity-0.83), the odds ratio (OR) for UNa+/UCreat to identify a poor diuretic response was 2.5 times greater, regardless of kidney function (OR for estimated glomerular filtration rate in the logistic regression model was 0.978 [0.945-1.013, P=0.222]). The UNa+/UCr ratio in a spot urine sample 2h after intravenous diuretic administration is a simple, highly predictive marker for the identification of AHF patients with poor diuretic response, surpassing guidelines-recommended markers like UNa+.

#1809 Twice against thrice-weekly hemodialysis: the TATH trial

Abstract Background and Aims Frequency of hemodialysis is still a debatable topic. Incremental hemodialysis has gained popularity and requires a smooth increase in dialysis frequency while maintaining a sufficient residual diuresis. In developing countries and some developed countries, a twice-weekly schedule independent of residual kidney function is still performed, sometimes because of lack of resources and some other times because of patients’ resistance to undergo three sessions per week. This study aimed to compare the survival of patients on twice versus thrice-weekly hemodialysis. Method This is a prospective, multicenter, non-randomized trial, that included incident patients on chronic hemodialysis between January 2018 and August 2021. Patients terminally ill were excluded. Patients were divided into two arms: twice-weekly and thrice-weekly hemodialysis. CASTOR eCRF (electronic case report form) was used for data capture. Demographics, comorbidities, laboratory tests, medications, residual diuresis and dialysis prescription were collected from the patients' medical records at dialysis initiation. Patients were followed at 1 month, 3 months, 6 months, one year and two years for their mortality, hospitalisations for pulmonary edema or hyperkalemia, uncontrolled severe hypertension and erythropoietin (EPO) dose requirement. This trial was terminated before reaching the required sample size of 800 because of the pandemic and economic crisis in the country. Missing baseline factors and covariates were imputed using multiple imputation algorithms, then entered in a logistic regression model to estimate propensity scores. A survival analysis with a cox-regression model including propensity score as a covariate assessed the difference between twice-weekly and thrice-weekly dialysis. This trial was registered on Clinicaltrials.gov ID NCT03415776. Results A total of 203 consecutive patients of 10 dialysis units were included, 133 in the thrice-weekly arm and 70 in the twice-weekly. Mean age was 67 ± 15 years, 54.2% were males, 55.5% had diabetes, 53.7% had coronary artery disease. Median eGFR at dialysis initiation was 6 (4, 8) mL/min/1.73 m2. Baseline median 24-hour diuresis was 500 (500, 1000) mL with higher diuresis in patients on twice-weekly (P = 0.051). Baseline mean hemoglobin was 9.6 ± 1.6 g/dL. 41.7% were initiated with AV fistula with more patients in the thrice-weekly initiated with temporary catheter. Median number of dialysis hours per week was 12 (10, 12) and 8 (8, 9) in thrice- and twice-weekly respectively. High-flux membranes with ultrapure dialysate were used in 55% of thrice-weekly and 74.3% of twice-weekly. Mean blood flow was 329 ± 76 mL/min. In univariate analysis, residual diuresis was significantly higher in twice-weekly at 1 month, 3 months (P = .002), 6 months (it dropped at 6 months to a median of 100 (0, 500) in thrice-weekly versus 225 (175, 875) in twice-weekly) and at one year (P = .015). Inter-dialytic weight gain and blood pressure levels were not statistically different at 1, 3, 6 months and one year. 22.5% of patients on thrice-weekly did not need antihypertensive medications at 6 months versus 12.1% in the twice-weekly. Serum potassium was significantly higher in twice-weekly at 3 months and at one year. Cumulative dose of EPO administered during 2 years was significantly higher in twice-weekly with a median of 720000 UI versus 500000 UI in thrice-weekly (P = .001) without a difference in hemoglobin but lower ferritin in twice-weekly (P = .005). There was no difference in hospitalisations' rates between the two arms. A cox regression model including propensity scores as a covariate did not show any survival difference between the two arms (Fig. 1). Conclusion Patients on twice-weekly hemodialysis had a similar survival and hospitalisations' rates at two years as patients on thrice-weekly hemodialysis. However, a twice-weekly schedule was accompanied with higher EPO dose requirements, higher serum potassium levels, more antihypertensive therapy despite more preserved residual diuresis.

Renal function and natriuresis-guided diuretic therapy-a pre-specified analysis from the PUSH-AHF trial.

In a randomized controlled trial, we recently showed that a natriuresis-guided diuretic approach improved natriuresis and diuresis in patients with acute heart failure (HF). In this pre-specified analysis, we investigated the association between (worsening) renal function, outcomes and the effect of intensive natriuresis-guided loop diuretic therapy as compared with standard of care. The Pragmatic Urinary Sodium-based algoritHm in Acute Heart Failure (PUSH-AHF) trial randomized patients to natriuresis-guided diuretic therapy or standard of care. Serum creatinine and estimated glomerular filtration rate (eGFR) were assessed at fixed timepoints, and worsening renal function (WRF) was assessed at 72 h. The primary outcome was the interaction between randomized treatment allocation, baseline eGFR and the dual primary outcome of PUSH-AHF: total natriuresis at 24 h and time to all-cause mortality or HF rehospitalization at 180 days. In 309 patients, median baseline eGFR was 53 (35-73) ml/min/1.73 m2, and 58% had eGFR <60 ml/min/1.73 m2. Baseline eGFR did not significantly modify the treatment effect of natriuresis-guided diuretic therapy on natriuresis at 24 h (p for interaction = 0.730). However, baseline eGFR significantly modified the effect on all-cause mortality and HF rehospitalization (p for interaction = 0.017): the risk of this second primary outcome was lower in patients with lower eGFR who were randomized to the natriuresis-guided group. In the natriuresis-guided arm, eGFR decreased more (-11.0 vs. -6.91 ml/min/1.73 m2; p = 0.002) during the first 3 days, but this effect was attenuated at discharge (-10.3 vs. -8.69 ml/min/1.73 m2; p = 0.38). WRF was more frequently observed in patients randomized to natriuresis-guided treatment, but was not associated with worse clinical outcomes. Natriuresis-guided diuretic treatment improved diuresis and natriuresis irrespective of baseline eGFR and occurrence of WRF, was effective even in patients with low eGFR, and the observed effect on eGFR was transient and not associated with worse clinical outcomes.

Intra-abdominal hypertension in acute decompensated heart failure - an overlooked piece in the puzzle of diuretic resistance

Abstract Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): Wroclaw Medical University, Insitute of Heart Diseases, Wroclaw, Poland. Introduction Intra-abdominal pressure (IAP) is a frequently overlooked aspect in clinical assessment which can have a significant impact on organ dysfunction in patients with acute decompensated heart failure (ADHF). Purpose To investigate prevalence and dynamics of IAP in patients with ADHF and its impact on diuretic response. Methods 30 patients admitted for ADHF, class III or IV in New York Heart Association classification were enrolled into a prospective, observational pilot study. In every individual serial transurethral IAP measurements, blood and urine samples were taken upon admission, on the second and the third day of hospitalization. Results The study showed 63.3% prevalence of intra-abdominal hypertension (IAH) defined as IAP ≥ 12 mmHg upon admission, while only roughly 13% presented overt signs of abdominal congestion. Patients diagnosed with IAH upon admission had significantly poorer diuresis in the first day of hospitalization, despite receiving similar doses of loop diuretics (p = 0.038). Moreover, IAP was negatively correlated with urine output (p = 0.011) and positively correlated with urine osmolality (p = 0.033), while there was no relationship between IAP and natriuresis. There was a significant reduction of IAP among patients with IAH treated according to the European Society of Cardiology guidelines. Conclusions The investigation revealed an exepctionally high prevalence of elevated IAP among patients hospitalized for ADHF and highlights the limitations of physical examination in assessing abdominal congestion, as most patients remain asymptomatic. The observed poorer diuresis in patients diagnosed with IAH and the established association between IAP and the reduced urinary output, despite achieving target levels of natriuresis, add another piece to the puzzle of understanding the phenomenon of diuretic resistance in ADHF and set directions for future studies.

Diagnostic Value of Urine Cytology in Pharmacologically Forced Diuresis for Upper Tract Urothelial Carcinoma Diagnosis and Follow-Up.

We performed a urine cytology analysis of a pharmacologically induced diuresis for the diagnosis of upper tract urothelial carcinoma. To evaluate the diagnostic value of cytology of pharmacologically forced diuresis, an initial cohort of 77 consecutive patients with primary upper tract urothelial carcinoma treated via radical surgery was enrolled. To evaluate pharmacologically forced diuresis cytology as a follow-up procedure, a second cohort of 1250 patients who underwent a radical cystectomy for bladder cancer was selected. In the first cohort, the sensitivity of cytology of pharmacologically forced diuresis in patients with invasive, high-grade, low-grade, and concomitant carcinoma in situ was 8%, 9%, 0%, and 14%, respectively. In the second cohort, cytology of pharmacologically forced diuresis was positive in 30/689 (4.3%) patients, in whom upper urinary tract recurrence was present in 21/30 (70%) of cases, and urethral recurrence was present in 8/30 (26%) of cases. As a follow-up tool, cytology of pharmacologically forced diuresis showed a sensitivity, specificity, and positive and negative predictive values of 60%, 99%, 70%, and 98%, respectively. Overall, as a diagnostic tool, the sensitivity of cytology of pharmacologically forced diuresis is slightly better in patients with invasive upper tract urothelial carcinoma and concomitant carcinoma in situ. As a follow-up method, positive cytology of pharmacologically forced diuresis is strongly related to cancer recurrence and can reveal urethral recurrence. Cytology of pharmacologically forced diuresis might be useful in cases with contraindications for imaging or when achieving endoscopic access to the upper urinary tract is difficult.

Efficacy and safety of sodium-glucose cotransporter 2 (SGLT2) inhibitors in patients with acute heart failure: a systematic review and meta-analysis.

The effectiveness and safety of a novel class of hypoglycemic medications known as sodium-glucose cotransporter 2 (SGLT2) inhibitors have not been completely established in relation to acute heart failure (AHF). Consequently, we sought to compare the prognostic and safety outcomes of patients administered SGLT2 inhibitors for the treatment of AHF. An extensive search of the Web of Science, PubMed, and EMBASE was conducted for randomized controlled trials and observational studies that have evaluated the use of SGLT2 inhibitors in AHF from the inception of these drugs to the present. We compiled data related to cardiovascular safety and prognosis. Aggregated risk ratios (RR), mean differences (MD), or standardized mean differences (SMD) were generated for all outcomes, with 95% confidence intervals (CIs), to evaluate the predictive significance of SGLT2 inhibitors in patients with AHF. We identified 4,053 patients from 13 studies. Patients experienced a substantial reduction in all-cause mortality (RR = 0.82, 95% CI: 0.70-0.96, P = 0.01), readmission rates (RR = 0.85, 95% CI: 0.74-0.98, P = 0.02), the number of heart failure exacerbation events (RR = 0.69, 95% CI: 0.50-0.95, P = 0.02), and the number of rehospitalization events due to heart failure (RR = 0.71, 95% CI: 0.58-0.86, P < 0.05) in the SGLT2 inhibitors-treatment group compared to a placebo or standard care (control group). SGLT2 inhibitors improved patient quality of life (SMD = -0.24, 95% CI: -0.40 to -0.09, P = 0.002). SGLT2 inhibitors were associated with enhanced diuresis in patients with AHF (MD = 2.83, 95% CI: 1.36-4.29, P < 0.05). Overall, treatment with SGLT2 inhibitors significantly reduced the level of serum NT-proBNP (MD = -497.62, 95% CI: -762.02 to -233.21, P < 0.05) and did not increase the incidence of adverse events (RR = 0.91, 95% CI: 0.82-1.01, P = 0.06). This meta-analysis suggests that treatment with SGLT2 inhibitors is associated with a better prognosis in patients with AHF than in patients not treated with SGLT2 inhibitors. It is safe and effective to initiate SGLT2 inhibitors in patients with AHF. https://www.doi.org/10.37766/inplasy2024.9.0015, identifier (INPLASY202490015).

How Much Furosemide Should be Administered to Prevent Transfusion-Associated Circulatory Overload? Results of a Dose-Finding Study

BACKGROUND: Transfusion-associated circulatory overload (TACO) is a common but under-reported complication of transfusion therapy, and results in significant morbidity and mortality. Pre-transfusion furosemide has been proposed as a mitigating strategy but has not received widespread endorsement, in part due to uncertainty regarding safe and effective dosing. An observational study was therefore conducted with the goal of creating a reliable dose-response curve in patients at high risk of TACO, using the statistical technique of Multiple Comparisons Procedure with Modelling (MCP-MOD). METHODS: Eligible patients were identified by screening bolus intravenous (IV) furosemide orders at two large academic hospitals. Eligibility criteria were selected to mimic those of a planned randomized controlled trial (RCT) of pre-transfusion furosemide for the prevention of TACO. Inclusion criteria were inpatients 50 years of age or older. Exclusion criteria were active bleeding, hemodynamic instability, glomerular filtration rate (GFR) &amp;lt; 30mL/min or need for dialysis, diuretic therapy (other than furosemide) administered less than 24 hours, furosemide (either IV or PO) administered less than 12 hours, or exogenous albumin administered less than 8 hours prior to index furosemide therapy. The primary outcome measure was the total volume of urine output in the six hours following IV furosemide administration. MCP-MOD analysis was performed after every 50 patients and continued until a weight-adjusted dose-response curve could be established with 100 mL precision, using the following covariates: age, sex, mean arterial pressure (MAP), serum albumin, GFR and history of chronic furosemide use. RESULTS: A total of 149 participants (53 female and 96 male) were enrolled over 2 years. As too few patients received doses exceeding 0.6 mg/kg to allow for a precise dose-response curve, only 132 patients receiving weight-adjusted doses ranging from 0.1 to 0.6 mg/kg were included in the MCP-MOD analysis. The characteristics of these patients are shown in Table 1. The dose-response curve formula that was derived from these patients was: Urine Output at 6 hours (mL) = 717.21 + 191.33 ln(dose (mg)/weight (kg)) + 0.73 × Age (years) + 103.37 × Sex (M=1/F=0) + 1.63 × GFR (ml/min) + 5.45 × MAP (mmHg) - 9.56 × albumin (g/L) - 62.31 × chronic diuretic use (Y=1/N-0) The curve with accompanying 95% confidence intervals is shown in Figure 1 This formula suggests that in an 80 kg patient with a GFR of 75 mL/min, a MAP of 85 mmHg, albumin of 40 g/L and no history of chronic diuretic use, 10 mg of IV furosemide should produce a diuresis of approximately 600 mL, sufficient to prevent circulatory overload from the transfusion of 1 unit of RBCs. A dose of 20 mg would be required to achieve a similar diuresis in patients with either a MAP &amp;lt; 60 mmHg, or a combination of both a GFR &amp;lt; 45 mL/min and a history of chronic diuretic use. CONCLUSIONS: A statistically precise dose-response curve for IV furosemide is possible with the inclusion of relevant clinical covariates, and can be used to guide dosing decisions in patients at risk of transfusion-associated circulatory overload. This formula derived from this study will inform the dosing recommendations of a planned RCT: Transfusion-Associated Circulatory Overload: Best Eliminated by Lasix® (TACO-BEL).

Intravenous Diuresis in Severe Precapillary Pulmonary-Hypertension-Related Right Heart Failure: Effects on Renal Function and Blood Pressure.

In patients with right heart failure (RHF) and pulmonary hypertension (PH), classical teaching often advises cautious diuresis in the setting of 'preload dependence' to avoid renal injury and hemodynamic compromise. However, while this physiology may hold true in some clinical settings, such as acute ischemia with right ventricular infarction, it cannot necessarily be extended to PH-related RHF. Rather, in patients with precapillary PH and decompensated RHF, diuresis aimed to decongest the right heart and systemic venous system may be directly beneficial. This study aimed to evaluate the effects of diuresis on renal function and blood pressure in patients with severe precapillary PH. A retrospective chart review was conducted on 62 patients with severe precapillary PH admitted for decompensated RHF. The hemodynamic phenotype of these patients was characterized by invasive hemodynamics and echocardiographic data. Laboratory and hemodynamic data were collected at both admission and discharge. After large-volume diuresis in this patient population, there was an improvement in both glomerular filtration rate and creatinine. While there was a decline in blood pressure after diuresis, this was not clinically significant, given the blood pressure remained in a normal range with improvement in renal function. In conclusion, this study demonstrated that despite concern for preload dependence, significant diuresis in patients with acute decompensated RHF from precapillary PH is not only safe but beneficial.

The clinical outcomes of dapagliflozin in patients with acute heart failure: A randomized controlled trial (DAPA-RESPONSE-AHF)

AimsDapagliflozin may confer additional decongestive and natriuretic benefits to patients with acute heart failure (AHF). Nonetheless, this hypothesis was not clinically examined. This study aimed primarily to investigate the effect of dapagliflozin on symptomatic relief in those patients. MethodsThis was a randomized, double-blind study that included 87 patients with AHF presenting with dyspnea. Within 24 h of admission, patients were randomized to receive either dapagliflozin (10 mg/day, N = 45) or placebo (N = 42) for 30 days. The primary outcome was the difference between the two groups in the area under the curve (AUC) of visual analogue scale (VAS) dyspnea score over the first 4 days. Secondary endpoints included urinary sodium (Na) after 2 h of randomization, percent change in NT-proBNP, cumulative urine output (UOP), and differences in mortality and hospital readmission rates. ResultsThe results showed that dapagliflozin significantly reduced the AUC of VAS dyspnea score compared to placebo (3192.2 ± 1631.9 mm × h vs 4713.1 ± 1714.9 mm × h, P < 0.001). The relative change of NT-proBNP compared to its baseline was also larger with dapagliflozin (−34.89% vs −10.085%, P = 0.001). Additionally, higher cumulative UOP was found at day 4 (18600 ml in dapagliflozin vs 13700 in placebo, P = 0.031). Dapagliflozin decreased rehospitalization rates within 30 days after discharge, while it did not affect the spot urinary Na concentration, incidence of worsening of heart failure, or mortality rates. ConclusionDapagliflozin may provide symptomatic relief and improve diuresis in patients with AHF. Further studies are needed to confirm these findings. https://clinicaltrials.gov/study/NCT05406505.

One-Month Treatment with Dapagliflozin Triggers Renal Water Conservation and Thus Prevents Osmotic Diuresis in Patients with Chronic Heart Failure

One-Month Treatment with Dapagliflozin Triggers Renal Water Conservation and Thus Prevents Osmotic Diuresis in Patients with Chronic Heart Failure

Evaluation of the Relationship between Diuresis and Kidney Function in Transplant Patients at Tabriz Imam Reza Hospital

Introduction Kidney transplantation is the method of choice and a cost-effective treatment for ESRD patients, which has significantly reduced mortality and complications of the disease. In this study, we aim to investigate the effects of diuresis on renal function in transplant patients. The aim of this cross-sectional analysis is to find out the effects of diuresis on renal function in patients undergoing renal transplantation. Methods This cross-sectional study was conducted on kidney transplant patients at Tabriz Imam Reza Medical Education Center. During the study, patients were examined based on specific inclusion and exclusion criteria. Demographic information, including age, sex, morning weight the day before surgery, underlying disease, and duration of dialysis in years, was recorded. The study also included calculating the patients’ GFR using the CKD-EPI equation and determining its relationship with both recovery urinary output and 24-hour urinary output. Results This study included 49 patients who underwent kidney transplantation. The right and the left kidney was transplanted in 42 and 7 patients respectively. Present study showed that there was no significant relationship between the laboratory parameters of patients, including preoperative sodium, preoperative potassium, preoperative urea, preoperative creatinine, postoperative sodium, postoperative potassium, postoperative urea, postoperative creatinine, preoperative GFR, postoperative GFR, and diuresis of patients in the recovery room and 24 hours after surgery. Additionally, there was no significant relationship between indicators such as age and weight and the amount of diuresis of patients in the recovery room and 24 hours after the operation. Furthermore, this study did not find a significant difference in preoperative GFR, postoperative GFR, recovery output, and 24-hour output between patients with hypertension and the non-hypertensive group. Conclusion There was no significant relationship between demographic indicators and laboratory parameters and the amount of diuresis in patients. Additionally, the study found no significant difference in GFR and output between patients with hypertension and those without hypertension.

Cardiovascular and renal effects of SGLT2 inhibitor initiation in acute heart failure: a meta-analysis of randomized controlled trials.

We sought to compare cardiovascular outcomes, renal function, and diuresis in patients receiving standard diuretic therapy for acute heart failure (AHF) with or without the addition of SGLT2i. Systematic search of three electronic databases identified nine eligible randomized controlled trials involving 2,824 patients. The addition of SGLT2i to conventional therapy for AHF reduced all-cause death (odds ratio [OR] 0.75; 95% CI 0.56-0.99; p = 0.049), readmissions for heart failure (HF) (OR 0.54; 95% CI 0.44-0.66; p < 0.001), and the composite of cardiovascular death and readmissions for HF (hazard ratio 0.71; 95% CI 0.60-0.84; p < 0.001). Furthermore, SGLT2i increased mean daily urinary output in liters (mean difference [MD] 0.45; 95% CI 0.03-0.87; p = 0.035) and decreased mean daily doses of loop diuretics in mg of furosemide equivalent (MD -34.90; 95% CI [- 52.58, - 17.21]; p < 0.001) without increasing the incidence worsening renal function (OR 0.75; 95% CI 0.43-1.29; p = 0.290). SGLT2i addition to conventional diuretic therapy reduced all-cause death, readmissions for HF, and the composite of cardiovascular death or readmissions for HF. Moreover, SGLT2i was associated with a higher volume of diuresis with a lower dose of loop diuretics.

Aerva lanata; A cure or a cause for kidney diseases; A brief overview

At present the phyto-preparations are widely used in clinical practice and among them Aerva lanata (A. lanata) is commonly known as “Polpala” in Sinhalese, which is prescribed to alleviate kidney diseases in Complementary and Ayurvedic Medicine (CAM). The infusion of the plant extract has resolved urolithiasis and has induced diuresis in patients relying on CAM therapy. Scientific data supports this traditional claim. However, a controversy exists that the prolong use of the plant material may cause renal damage. Scientific literature also does not put forth the negative effects of using a long-term basis, though the dried plant preparations are readily available in the form of herbal tea in many countries. Therefore, this overview is a compilation of both the beneficial and detrimental effects of the use of plant material as a treatment in kidney diseases. Evaluation of the current literature supports the belief of nephrotoxicity in long term administration over its reported nephroprotection. Thus, the author reports that people who tend to self-medicate with A. lanata should be vigilant due to its possible adverse effects.

MO130GLOMERULAR FILTRATION RATE IS THE MAIN PREDICTOR OF URINE OUTPUT IN AUTOSOMAL DOMINANT POLYCYSTIC KIDNEY DISEASE (ADPKD) PATIENTS TREATED WITH TOLVAPTAN

Abstract Background and Aims Tolvaptan was approved to treat autosomal dominant polycystic kidney disease (ADPKD) to slow the rate of kidney growth and renal function decline. Tolvaptan blocks the V2 vasopressin receptor in renal collecting ducts and distal nephron causing intense polyuria. Few authors have analyzed what factors influence the volume of diuresis in patients taking tolvaptan. Method We have analyzed the influence of solute excretion and glomerular filtration rate, besides age and gender as predictors of urine output, using multivariable analysis. In concret, we have searched the importance of osmolar excretion as predictor of volume of diuresis. Results We studied 24 h-urine samples from 18 ADPKD patients on treatment with tolvaptan, who had received the three doses: 45/15, 60/30 and 90/30 mg. Each patient was represented once per dose, for a total of 54 urine samples (Table 1). Tolvaptan increased urine volume, which was roughly doubled, and roughly halved urine solute concentrations expressed by volume and calculated osmolality. By contrast, solute concentrations expressed as ratios with creatinine remained constant as did osmolality corrected with urinary creatinine, indicating that there was no change in solute excretion after tolvaptan. Urine volume was correlated with serum creatinine (Rho= -0.36, p= 0.008), urinary creatinine (Rho = -0.29, p = 0.034) and GFR-MDRD4 (Rho = 0.44, p= 0.001). Urine volume was correlated with calculated daily osmolar excretion in Osm/day (Rho = 0.76, p &amp;lt;0.001). Urine volume was not correlated with calculated urinary osmolality in mOsm/Kg (Rho= -0.04, p= 0.77) or as urinary osmolality/creatinine ratio (Rho= 0.23, p= 0.1). Correlation of urine volume with osmolar excretion was lost when urine volume was removed from the predictor variable. Urine volume was additionally not correlated with urinary urea o sodium concentrations nor their solute/creatinine ratios, and although it was correlated with urinary potassium concentration (Rho = -0.33, p=0.014), it was not correlated with potassium/creatinine ratio. We also performed a linear regression analysis searching predictors of urine volume. Only GFR and the osmolality/creatinine ratio were significant predictors of urine volume (urine volume= 55.35 x GFR + 4.74 x Osmolality/Cr; r2= 0.41, p&amp;lt;0.001) but individual solute assessments or tolvaptan dose did not predict urine volume. Conclusions Therefore, urine volume after initiating tolvaptan in patients with ADPKD is influenced mainly by the degree of renal function. There might also be a contribution of urinary solute load but it can not be studied using total solute excretion due to collinearity. We propose that the urinary solute/creatinine ratio and osmolality/creatinine ratio should be used to search for predictors of urine output in patients on tolvaptan.

The safety outcomes of sodium-glucose cotransporter 2 inhibitors in patients with different renal function: A systematic review and meta-analysis

AimsWe aimed to assess whether the safety outcomes exerted by sodium-glucose cotransporter 2 (SGLT2) inhibitors were associated with different renal function at baseline. Data SynthesisWe searched randomized controlled trials comparing SGLT2 inhibitors with placebo in participants simultaneously involving the entire range of estimated glomerular filtration rate (eGFR) levels at baseline in one study. According to eGFR, we divided the population into two subgroups with eGFR <60 ml/min/1.73 m2 and eGFR≥60 ml/min/1.73 m2. Data from the CANVAS program, CREDENCE, EMPA-REG OUTCOME, DECLARE–TIMI 58, DAPA-HF, and EMPA-REG RENAL were included. SGLT2 inhibitors significantly reduced the risk of all serious adverse events (HR 0.91 [95% CI 0.87 to 0.95], p < 0.001) and acute kidney injury (HR 0.74 [95% CI 0.64 to 0.85], p < 0.001). Except for high risk of genital infection, SGLT2 inhibitors did not increase the risk of amputation, fracture, hyperkalemia, hypoglycemia, volume depletion, or urinary tract infection. Further analyses showed that these safety outcomes were similar between subgroups (p-interaction > 0.05). For osmotic diuresis, SGLT2 inhibitors significantly increased the risk by 75% (p = 0.036), and subgroup analyses showed that this effect was completely attributed to the increase in patients with eGFR ≥60 ml/min/1.73 m2 (p-interaction<0.001). ConclusionThe indication of no risk of osmotic diuresis in patients with eGFR<60 ml/min/1.73 m2 and the consistency of other safety outcomes across different baseline renal function may allow additional individuals to safely use SGLT2 inhibitors.

Continuous Intravenous Infusion of Bumetanide to Achieve Diuresis in Patients with Congestive Heart Failure and Chronic Kidney Disease: A Rapid Review

Bumetanide falls in the class of loop diuretics like furosemide. The effects of both have been extensively researched and are well documented. In medical practice furosemide is more widely used in patients both orally and through intravenous administration.

Management of heart failure in cardiac amyloidosis using an ambulatory diuresis clinic

Recurrent congestion in cardiac amyloidosis (CA) remains a management challenge, often requiring high dose diuretics and frequent hospitalizations. Innovative outpatient strategies are needed to effectively manage heart failure (HF) in patients with CA. Ambulatory diuresis has not been well studied in restrictive cardiomyopathy. Therefore, we aimed to examine the outcomes of an ambulatory diuresis clinic in the management of congestion related to CA. We retrospectively studied patients with CA seen in an outpatient HF disease management clinic for (1) safety outcomes of ambulatory intravenous (IV) diuresis and (2) health care utilization. Forty-four patients with CA were seen in the clinic a total of 203 times over 6 months. Oral diuretics were titrated at 96 (47%) visits. IV diuretics were administered at 56 (28%) visits to 17 patients. There were no episodes of severe acute kidney injury or symptomatic hypotension. There was a significant decrease in emergency department and inpatient visits and associated charges after index visit to the clinic. The proportion of days hospitalized per 1000 patient days of follow-up decreased as early as 30 days (147.3 vs 18.1/1000 patient days of follow-up, P< .001) and persisted through 180 days (33.6 vs 22.9/1000 patient days of follow-up, P< .001) pre- vs post-index visit to the clinic. We demonstrate the feasibility of ambulatory IV diuresis in patients with CA. Our findings also suggest that use of a HF disease management clinic may reduce acute care utilization in patients with CA. Leveraging multidisciplinary outpatient HF clinics may be an effective alternative to hospitalization in patients with HF due to CA, a population who otherwise carries a poor prognosis and contributes to high health care burden.