Diuretic Resistance In Patients Research Articles

Abstract 15479: High Output Cardiac Failure Associated With Arteriovenous Fistula

Introduction: High output heart failure (HOHF) secondary to arteriovenous fistula (AVF) is known. However, having a high index of suspicion for the latter when encountering diuretic resistance in patients with a remote history of hemodialysis is key. Case A 68-year-old female with a history of kidney transplant in 2012 with no recent dialysis, hypertension, hyperlipidemia, pulmonary hypertension, heart failure with reduced ejection fraction, and atrial fibrillation presented with decompensated heart failure and acute kidney injury (AKI). Physical exam was remarkable for anasarca, and no apparent fistulas were noted. She was started on milrinone and furosemide drips. Clinical decision making Initial transthoracic echocardiogram (TTE) revealed an ejection fraction (EF) of 20%, which declined from 35%, along with new mitral and tricuspid regurgitation. Her hospitalization was complicated by altered mental status, worsening AKI requiring hemodialysis, atrial fibrillation with rapid ventricular response, and resistance to multiple diuretics and after-load reduction combinations. Diuretics and inotropic support were discontinued due to worsening clinical status. Given concerns for valvular disease, a transesophageal echocardiogram was obtained, confirming moderate to severe mitral and tricuspid valve regurgitation, bi-atrial enlargement, and reduced biventricular function. However, the patient was not clinically optimized for Mitra-clip. Further hemodynamics and volume status assessment with RHC revealed a mean PAP 44, PCWP 26, and CO 11 L/min. RHC results raised suspicion for HOHF. Interestingly, the patient was noted to have a right inguinal surgical scar with a palpable thrill, and an arteriovenous graft duplex revealed high volume flow. The patient underwent ligation of the right inguinal fistula. Repeat TTE two weeks post AVF ligation showed EF of 40% and improved functional mitral and tricuspid valve regurgitation. The patient ultimately was taken off hemodialysis and had clinically improved heart failure. GDMT was optimized, and outpatient evaluation for mitral valve intervention was scheduled. Conclusion Longstanding AVF can cause HOHF. Early index of suspicion is warranted for AVF ligation as it results in rapid EF recovery.

Factors predicting diuretic resistance in patients with acute decompensated heart failure

Abstract Background Heart failure is a leading cause of hospitalisation and mortality with high incidence and ever-increasing prevalence in the world. Although novel methods in management of acute decompensated heart failure (ADHF) have been developed, mortality and rehospitalisation rates remain high. Loop diuretics have been shown to be effective in relieving congestion and have been recommended in many heart failure guidelines. Continuous use of loop diuretics may cause complications in the form of diuretics resistance. The prevalence of diuretic resistance ranges from 20–35% in the heart failure population and has been shown to be a predictor of mortality and an increased incidence of hospitalisation. Until now there are debates in determining the clinical indicators of diuretic resistance. However, the clinical characteristics of patients with acute decompensated heart failure that predict the development of diuretic resistance have not been widely studied and previous studies have shown different results from one another. Purpose This study aims to identify factors that influence the occurrence of diuretic resistance in ADHF patients based on clinical profiles, medical histories, and laboratory findings. Methods This was a retrospective cohort study on patients treated due to ADHF from January-December 2019. Diuretic resistance was defined as a diuresis response less than 1400 ml in the first 24 hours after administration of 40 mg of intravenous furosemide. Results Data from 535 patients were analysed. The prevalence of diuretic resistance in this study was 68%. Independent predictors obtained from multivariate logistic regression analysis were Type II Diabetes Mellitus (p=0.013), history of prior iv loop diuretics >6 days (p=0.002), history of oral loop diuretic dose >80 mg/day (p=0.006), LVEF ≤49% (p=0.002), BUN ≥21 mg/dL (p<0.001) and serum chloride <98 mmol/L (p<0.001). In addition, a scoring system has been generated from the final model with AUC 0.749. Conclusions Independent predictors for diuretic resistance obtained from this study were DM, history of prior iv loop diuretics >6 days, history of oral loop diuretic dose >80 mg/day, LVEF ≤49%, BUN ≥21 mg/dL and serum chloride <98 mmol/L. Funding Acknowledgement Type of funding sources: None.

Diuretic resistance in patients with chronic heart failure: mechanisms, prevention, and treatment

The authors analyzed the problem of diuretic resistance (DR) in patients with chronic heart failure (CHF). Most of the symptoms and signs of CHF are associated with hypervolemia and vascular congestion in the systemic and pulmonary circulation. The severity of the latter is the main factor which negatively affects the overall assessment of life satisfaction in patients with CHF. Since the patient, even at the incurable stage of CHF, primarily expects a rapid decrease in the severity of manifestations of decompensation from the prescribed therapy, achieving euvolemia is the essence of its short-term objective. Without diuretics, these immediate effects, according to which most CHF patients judge the qualifications of the doctor, are almost impossible to achieve. Unfortunately, apparently, not a single clinician was able to avoid disappointment in the effectiveness of CHF therapy associated with DR in their practice. As a rule, DR reflects the progressive course of CHF and is often associated with a poor prognosis. The review consistently covers the issues of terminology, diagnosis, pathogenesis, and prevention of DR, which aggravates CHF, and discusses measures aimed at restoring sensitivity to diuretics.

Chlorthalidone and Advanced Chronic Kidney Disease.

Chlorthalidone and Advanced Chronic Kidney Disease.

First-in-Man Use of the Percutaneous 10F Reitan Catheter Pump for Cardiorenal Syndrome.

Cardiorenal syndrome worsens outcome in patients with decompensated chronic heart failure, and complicates recompensation by medical therapy. Mechanical circulatory support has the potential to improve renal function, and likely mitigates diuretic resistance in patients with severe cardiorenal syndrome. The Reitan catheter pump (RCP) is a novel temporary percutaneous circulatory support system for reducing cardiac afterload and increasing renal preload. Here, we report on the first-in-man use of the 10F-version of the RCP device, which was associated with favorable effects on hemodynamics and diuresis. Further investigation to evaluate safety and efficacy of this promising approach is warranted.

Effectiveness of Zhuling decoction on diuretic resistance in patients with heart failure: a randomized, controlled trial.

To test the effects of Zhuling decoction on patients with diuretic resistance in heart failure compared with a group of patients undergoing conventional treatment alone. This research was a prospective, randomized, controlled study. From July 2018 to August 2020, 96 diuretic resistance patients from the Cardiovascular Research Center of Taicang Hospital affiliated with Nanjing University of Traditional Chinese Medicine (Grade III Hospital of Traditional Chinese Medicine) were enrolled in the study. The subjects were randomly divided into an observation group (48 cases) and a control group (48 cases). Patients in both groups received conventional treatment. In addition, observation group patients received Traditional Chinese Medicine Zhuling decoction. The primary endpoint was the urine output mean difference between Day 1 and Day 7 after treatment. Secondary endpoints were the changes over time in the N-terminal pro-B type natriuretic peptide (NT-proBNP), New York Heart Association (NYHA) functional classification, and Minnesota Living with Heart Failure Questionnaire (MLHFQ). The safety and tolerability of the drug were comprehensively evaluated based on adverse drug reactions, as well as laboratory-assisted tests for liver and kidney function and electrolytes. Significant improvements were demonstrated for urine output in the two groups at Day 7, with a 1325 1045 mL difference in favor of the observation group ( = 0.018). The observation group also had greater improvements in NT-proBNP and NYHA functional classification changes than the control group. At the 30th day of follow-up, a significant reduction in negative findings on the MLHFQ from baseline was observed in both groups, but the observation group demonstrated a significantly greater reduction than the control group ( <0.001). Zhuling decoction could be used in combination therapy for patients with diuretic resistance in heart failure in addition to standard treatment.

Use of loop diuretics in chronic heart failure: do we adhere to the Hippocratian principle 'do no harm'?

Use of loop diuretics in chronic heart failure: do we adhere to the Hippocratian principle 'do no harm'?

Abstract 14608: Prognostic Value of Diuretic Resistance in Patients Admitted for Acute Decompensated Heart Failure With Reduced, Mid-range, or Preserved Left Ventricular Ejection Fraction

Background: Diuretic resistance is associated with poor clinical outcome in patients with acute decompensated heart failure (ADHF). However, little information is available on the prognostic significance of diuretic resistance in ADHF patients, relating to reduced, mid-range, or preserved left ventricular ejection fraction (LVEF). Methods: We studied 400 consecutive patients who were admitted for ADHF and survived to discharge. Diuretic resistance (DR) was defined by furosemide dose per body weight (BW) at discharge. Patients were classified by DR, and high dose group (higher DR) was defined by furosemide dose of &gt; median value of DR (0.580). The endpoint was a composite of all-cause mortality and unplanned hospitalization for worsening heart failure. Results: There were 139 patients with heart failure with reduced LVEF (HFrEF, LVEF&lt;40%), 86 with mid-range LVEF (HFmrEF, 40%≤LVEF&lt;50%) and 175 with preserved LVEF (HFpEF, LVEF≥50%). There was no significant difference in DR among the three groups (HFrEF; median 0.541 [IQR 0.360-0.786] mg/kg vs HFmrEF; 0.606 [0.398-0.820] mg/kg vs HFpEF; 0.624 [0.380-0.935] mg/kg, p=NS). During follow-up of 2.4±1.6 years, 195 patients reached the endpoint (HFrEF, n=67, HFmrEF, n=44, and HFpEF, n=84). In multivariate Cox analysis, DR was significantly associated with the endpoint independently of age, estimated glomerular filtration rate, plasma brain natriuretic peptide level and LVEF only in HFpEF patients (p&lt;0.0001). Kaplan-Meier analysis showed that the risk of the endpoint was significantly higher in the patients with higher DR in HFpEF patients, but not in HFrEF or HFmrEF patients (Figure). Conclusions: In this study, higher DR was shown to be associated with poor clinical outcome in HFpEF patients admitted with ADHF.

Multiple Targets on Sodium Excretion with SGLT2 Inhibitors, Furosemide, and Spironolactone Improves Diuretic Resistance in Patients with Diabetic Nephropathy on CKD Stage 3-4: A Pilot Study

Multiple Targets on Sodium Excretion with SGLT2 Inhibitors, Furosemide, and Spironolactone Improves Diuretic Resistance in Patients with Diabetic Nephropathy on CKD Stage 3-4: A Pilot Study

Taking on Diuretic Resistance in Patients with Acute Heart Failure

Diuretic resistance creates challenges in the management of acute decompensated heart failure (HF). Current guidelines, based only on expert consensus,

A Single-Center Retrospective Study on the Initiation of Peritoneal Dialysis in Patients With Cardiorenal Syndrome and Subsequent Hospitalizations.

Background:Inotropic dependence and diuretic resistance in patients with cardiorenal syndrome (CRS) lead to frequent hospitalizations and are associated with high mortality. Starting peritoneal dialysis (PD) acutely (within 2 weeks of a heart failure hospitalization) offers effective volume removal without hemodynamic compromise in this population. There is little data on this approach in the North American literature.Objective:To determine whether volume-overloaded patients with CRS on maximal doses of diuretic therapy had reduced hospitalization for heart failure following PD initiation.Design:Retrospective cohort study.Setting:Academic hospital network (University Health Network, Toronto, Ontario).Patients:Patients with CRS receiving a bedside catheter and starting PD within 2 weeks of insertion at the University Health Network from January 1, 2013, to December 31, 2018.Methods and measurements:Data for heart failure–related hospitalizations and length of stay 6 months before and after PD initiation were collected. Patients who died, switched to hemodialysis, or were transferred to another facility within 6 months of starting PD were excluded from the analysis.Results:We identified 31 patients with CRS who had a bedside PD catheter inserted. The average age of patients was 66.0 ± 13.0 years. There were 7 (22.6%) deaths and 4 (12.9%) transfers to other programs or hemodialysis within 6 months of catheter insertion. After exclusion, we analyzed hospitalization and length of stay data for 20 patients. The hospitalization rate 6 months before PD initiation was 6.9 admissions per 1000 patient-days. This decreased to 2.5 admissions per 1000 patient-days after PD initiation. In addition, there was also a significant reduction in the average length of stay per hospitalization (24.1-3.9 days; P = .001).Limitations:Our study did not assess the severity of heart failure symptoms using a standardized functional classification system. We did not assess quality of life and illness intrusiveness scores before and after starting dialysis, nor did we capture non–heart-failure-related hospitalizations or external admissions at other hospital sites. We limited eligibility to clinically stable patients with no prior major abdominal surgical history in a single Canadian PD program using bedside ultrasound approach for catheter insertions by experienced nephrologists and included a small number of patients.Conclusions:Volume-overloaded patients with CRS receiving maximal diuretic therapy have lower hospitalization rates and shorter stays after initiation of PD. The development of a bedside PD catheter insertion program and close collaboration between nephrology and cardiology services may facilitate acute start dialysis in this population.

Diuretic resistance in patients with heart failure: Clinical characteristics and predictors of outcome

Background: Our aim was to study the clinical characteristics and predictors of mortality in heart failure (HF) with diuretic resistance. Methods: We conducted a 5-year retrospective study on 119 HF patients with diuretic resistance at Tikur Anbessa Specialized Teaching Hospital. The primary endpoint was mortality. We compared baseline characteristics and assessed association in patients who received high-dose (≥120 mg) versus low-dose (

Web Exclusive. Annals On Call - Diuretic Resistance.

In this episode of Annals On Call, Dr. Centor discusses diuretic resistance in patients with heart failure with Dr. Joel Topf. Listeners will gain knowledge to help make better-informed choices whe...

心衰患者利尿剂抵抗的研究进展

心衰患者利尿剂抵抗的研究进展

A perspective on diuretic resistance in chronic congestive heart failure.

Chronic congestive heart failure (CHF) is a complex disorder characterized by inability of the heart to keep up the demands on it, followed by the progressive pump failure and fluid accumulation. Although the loop diuretics are widely used in heart failure (HF) patients, both pharmacodynamic and pharmacokinetic alterations are thought to be responsible for diuretic resistance in these patients. Strategies to overcome diuretic resistance include sodium intake restriction, changes in diuretic dose and route of administration and sequential nephron diuretic therapy. In this review, we discuss the definition, prevalence, mechanism of development and management strategies of diuretic resistance in HF patients.

Renal tubular resistance is the primary driver for loop diuretic resistance in acute heart failure.

Loop diuretic resistance is a common barrier to effective decongestion in acute heart failure (AHF), and is associated with poor outcome. Specific mechanisms underlying diuretic resistance are currently unknown in contemporary AHF patients. We therefore aimed to determine the relative importance of defects in diuretic delivery vs. renal tubular response in determining diuretic response (DR) in AHF. Fifty AHF patients treated with intravenous bumetanide underwent a 6-h timed urine collection for sodium and bumetanide clearance. Whole-kidney DR was defined as sodium excreted per doubling of administered loop diuretic and represents the sum of defects in drug delivery and renal tubular response. Tubular DR, defined as sodium excreted per doubling of renally cleared (urinary) loop diuretic, captures resistance specifically in the renal tubule. Median administered bumetanide dose was 3.0 (2.0-4.0) mg with 52 (33-77)% of the drug excreted into the urine. Significant between-patient variability was present as the administered dose only explained 39% of variability in the quantity of bumetanide in urine. Cumulatively, factors related to drug delivery such as renal bumetanide clearance, administered dose, and urea clearance explained 28% of the variance in whole-kidney DR. However, resistance at the level of the renal tubule (tubular DR) explained 71% of the variability in whole-kidney DR. Defects at the level of the renal tubule are substantially more important than reduced diuretic delivery in determining diuretic resistance in patients with AHF.

Ultrasound Assessment of Kidney Volume in Patients with Acute Decompensated Heart Failure: A Predictor of Diuretic Resistance

Diuretics are essential for treating acute decompensated heart failure (ADHF), but the response is inconsistent. This study aimed to clarify whether kidney volume as assessed by ultrasound (US) predicts diuretic resistance in patients with ADHF. We enrolled 29 patients with ADHF and 32 controls. Height-adjusted kidney volume was assessed by US. We divided patients into two groups based on the median value of total daily use of furosemide (intravenous dose plus 0.5 × oral dose of furosemide equivalents) during 3 days from admission. Patients with ADHF had a significantly smaller left kidney volume than did control subjects (27.7 ± 10.0 vs. 32.8 ± 8.8 mL/m, P < 0.05). Patients in the high-dose furosemide group (≥ 51.7 mg/d) had a significantly lower estimated glomerular filtration rate (eGFR) and a significantly smaller kidney volume than did those in the low-dose furosemide group (eGFR: 43.9 ± 20.4 vs. 60.8 ± 21.6 mL/min/1.73 m2, left kidney volume: 23.2 ± 5.2 vs. 32.6 ± 11.0 mL/m, right kidney volume: 26.5 ± 7.5 vs. 32.6 ± 7.9 mL/m, all P < 0.05). Multivariate logistic analysis showed that left kidney volume, but not eGFR, was independently associated with the requirement of high-dose furosemide (odds ratio: 0.856, 95% confidence interval: 0.735-0.997, P < 0.05). Kidney volume as assessed by US is a useful predictor of diuretic resistance in patients with ADHF.

Treating Diuretic Resistance: An Overview.

Loop diuretics are central to the management of fluid overload in acute decompensated heart failure. However, a variance in the response to loop diuretics can alter a patient's clinical course and has an adverse effect on clinical outcomes. Thus, a diminished response to loop diuretics is an important clinical issue. Factors thought to contribute to diuretic resistance include erratic oral absorption in congested states and postdiuretic sodium retention. Further contributing to diuretic resistance in patients with advanced heart failure are decreases in renal perfusion and alterations in sodium handling that occur in an attempt to maintain circulatory homeostasis. Several pharmacologic interventions have been used to improve diuretic response. Intravenous diuretic administration, increasing diuretic doses, or changing diuretic agents can potentially overcome pharmacokinetic obstacles which contribute to drug resistance. Combination diuretic therapy may be useful to overcome increased sodium retention, dopamine may improve renal perfusion, and hypertonic saline may transiently increase intravascular volume and improve sodium delivery to the tubules of the nephron. Despite the prevalence of diuretic resistance, there remains a paucity of clinical trial evidence to help guide therapy in these patients.

Co-administration of furosemide with albumin for overcoming diuretic resistance in patients with hypoalbuminemia: A meta-analysis

PurposeTo systematically review clinical studies of co-administration of albumin and loop diuretics in hypoalbuminemic patients as a strategy to overcome diuretic resistance. Materials and MethodsSystematic search of electronic databases up to October 2012. We included randomized clinical trials of adults with hypoalbuminemia, comparing co-administration of loop diuretics and albumin versus loop diuretics alone. Quantitative data were synthesized with meta-analytic techniques for clinical, surrogate (urinary volume and urinary sodium excretion) and intermediate (pharmacokinetic and hemodynamic parameters) outcomes. ResultsTen studies were included, of which 8 trials with crossover design were synthesized with meta-analysis. A statistically significant increase in the amount of urine volume (increment of 231 mL [95% confidence interval 135.5-326.5]) and sodium excreted (15.9 mEq [4.9-26.8]) at 8 hours were found in favor of co-administration of albumin and furosemide. These differences were no longer statistically significant at 24 hours. Meta-analyses for intermediate outcomes (ie, furosemide excretion, distribution volume etc.) did not reveal statistically significant differences. ConclusionsSynthesis of a heterogeneous body of evidence shows transient effects of modest clinical significance for co-administration of albumin with furosemide in hypoalbuminemic patients. Pragmatic, large-scale randomized studies are needed to delineate the role of this strategy.

Increased Sensitivity to Arginine Vasopressin May Play an Important Role in Diuretic Resistance in Patients with Heart Failure

Increased Sensitivity to Arginine Vasopressin May Play an Important Role in Diuretic Resistance in Patients with Heart Failure