Doses Of Furosemide Research Articles

Repetitive use of levosimendan in severe functional tricuspid regurgitation.

Functional tricuspid regurgitation (FTR) has a very poor outcome and few patients are referred for surgery due to the important peri-operative mortality which averages 15%.1 Edge-to-edge percutaneous repair has been proposed as an alternative to cardiac surgery and preliminary results showed improvement in patient’s functional status and outcome. However, the feasibility is limited in patients with advanced FTR disease, i.e. in case of a large gap of leaflet coaptation.2 Levosimendan is a calcium sensitizer agent which enhances cardiac contractility and has a strong vasodilatation effect. Levosimendan seems particularly efficient in improving right ventricular (RV) function. The benefit of the repetitive use of levosimendan in chronic heart failure (HF) has been demonstrated,3 but no study has been conducted in patients with severe FTR. In this preliminary clinical study, we reported the clinical and echocardiography impacts of the repetitive use of levosimendan in HF patients with severe FTR. We prospectively included 33 consecutive patients (77 ± 7 years, 48.5% of women) admitted for HF with severe FTR [73% graded as massive or torrential, mean effective regurgitation orifice area (EROA) = 100 ± 56 m²]. All patients signed informed consent. Most of the patients were in NYHA Class III and IV (91%) with a median dose of furosemide at 250 mg daily (95; 500). The majority were in chronic atrial fibrillation (92%), 51.5% had a history of cardiac surgery, and 42.4% had a pacemaker or defibrillator lead. Surgery was denied by the Heart Team because of the operative risk (mean Triscore = 25 ± 17%) and the percutaneous approach was first excluded because of inappropriate anatomy or imaging. Levosimendan was delivered without bolus by intravenous perfusion (0.2 γ/kg/min over 24 h) and repeated at least one time after 2 or 3 weeks. The severity of TR was graded according to EROA using the PISA (proximal isovelocity surface area) method3 by transthoracic echocardiography. Tricuspid annulus diameter, tricuspid leaflet tenting and coaptation, and RV and right atrial (RA) dimensions were quantified from a four-chamber view and inferior vena cava (IVC) diameter was assessed in the subcostal view. Right ventricular function was assessed using tricuspid annular plane systolic excursion (TAPSE).

Severe electrolyte disorders after overdosing of furosemide, spironolactone and captopril in infants with congenital heart defects: A case series

Six cases of severe electrolyte disorders with acute kidney failure after overdosing on furosemide, spironolactone and captopril were reported. All of them were less than six months of age with congenital heart defects and were treated by cardiologists with a dosage of less than 2mg/kg of furosemide, spironolactone, and captopril per day. However, their parents gave them the wrong dose, as a result, all children received higher doses of both furosemide (8.8 – 13.3mg/kg/day), spironolactone and captopril (5.5 – 8.3mg/kg/day). This led to severe hyponatremia, hyperkalemia, and acute kidney injury. All six patients were treated and eventually recovered without any complication.

Predictors and Outcomes of SGLT2 Inhibitor Discontinuation in a Real-World Population after Hospitalization for Heart Failure

Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce mortality and morbidity in patients with heart failure (HF), but are discontinued in some patients. Such patients may not enjoy favorable benefits of SGLT2i therapy. We evaluated the risk factors for SGLT2i discontinuation in a real-world population with HF. We retrospectively included consecutive patients who were hospitalized for HF and administered SGLT2i during the index hospitalization between February 2016 and September 2021. We assessed the baseline clinical factors associated with post-discharge discontinuation of SGLT2i. This study included a total of 159 patients (median age = 73 years, 57 women). Among baseline characteristics, a lower serum albumin level (odds ratio = 0.23, 95% confidence interval = 0.07-0.76, p = 0.016) and a higher dose of furosemide (odds ratio = 1.02, 95% confidence interval = 1.00-1.05, p = 0.046) were independently associated with the future discontinuation of SGLT2i following index discharge. Patients who terminated SGLT2i (n = 19) had a higher incidence of HF recurrence or cardiovascular death during the 1-year therapeutic period (32% versus 11%, p = 0.020). Among patients who initiated SGLT2i during hospitalization for HF, lower serum albumin levels and higher doses of loop diuretic at index discharge were associated with the discontinuation of SGLT2i following index discharge. We should pay special attention to patients with such characteristics during the initiation of SGLT2i and during SGLT2i therapy.

Real-Life Data on Readmissions of Worsening Heart Failure Outpatients in a Heart Failure Clinic.

Introduction Recurrent hospitalizations for worsening heart failure (WHF) represent a major global public health concern, resulting in significant individual morbimortality and socioeconomic costs. This real-life study aimed to determine the rate and predictors of readmission for WHF in a cohort of outpatients with chronic heart failure (CHF) followed in a heart failure clinic (HFC) at a university hospital. Methods We conducted a longitudinal, observational, and retrospective study of all consecutive CHF patients seen at the HFC of the São Francisco Xavier Hospital, Lisbon, by a multidisciplinary team in 2019. The patients were followed for one year and were on optimized therapy. The inclusion criteria for the study were patients who had been hospitalized and subsequently discharged at least three months prior to their enrollment. Patient demographics, heart failure (HF) characterization, comorbidities, pharmacological treatment, treatments of decompensated HF in the day hospital (DH), hospitalizations for WHF, and death were recorded. We applied logistic regression analysis to assess predictors of hospital readmission for HF. Results A total of 351 patients were included: 90 patients (26%) had WHF requiring treatment with intravenous diuretics in the DH; 45 patients (mean age: 79.1 ± 9.0 years) were readmitted for decompensated HF within one year (12.8%) with no gender difference, while 87.2% of the patients (mean age: 74.9 ± 12.1 years) were never readmitted. Readmitted patients were significantly older than those who were not (p=0.031). Additionally, they had a higher New York Heart Association (NYHA) functional classification (p<.001), were on a higher daily dose of furosemide (p=0.008) at the time of the inclusion visit, were more frequently affected by the chronic obstructive pulmonary disease (COPD) (p=0.004); had been treated more often in the DH for WHF (p<.001) and had a higher mortality rate (p<.001) at one year. Conclusions This study aimed to determine WHF patient readmission rates and predictors. According to our results, a higher NYHA class, the need for treatment in the DH for WHF, a daily dose of furosemide equal to or greater than 80 mg, and COPD were predictors of readmission for WHF. CHF patients continue to experience WHF and recurrent hospitalizations despite therapeutic advances and close follow-up in the HFC with the multidisciplinary team. Besides COPD, the HF readmission risk factors found were mainly related to advanced disease. Furthermore, the structured and multidisciplinary approach of our disease management program likely contributed to our relatively low rate of readmissions.

Effect of sacubitril/valsartan on natriuretic peptide in patients with compensated heart failure.

The time-dependent changes in the natriuretic peptide families during sacubitril/valsartan (S/V) treatment remain obscure in the Asian heart failure (HF) cohort. Eighty-one outpatients with compensated HF were analyzed. The patients were divided into two groups based on the administration of S/V (n = 42) or angiotensin converting enzyme inhibitor (ACE-I; n = 39). Changes to the natriuretic peptide families and the daily dose of loop diuretics were evaluated 3 and 6months after the intervention. The atrial natriuretic peptide (ANP) level was significantly increased (102 [63-160] pg/mL to 283 [171-614] pg/mL [3months]; 409 [210-726] pg/mL [6months]) in the S/V group but not in the ACE-I group. The dose of furosemide was significantly decreased during the six-month follow-up period in the S/V group (40 [20-40] mg to 20 [10-20] mg) but not in the ACE-I group. A multivariate logistic regression model showed that the presence of persistent atrial fibrillation (AF) and HF with a preserved left ventricular ejection fraction (HFpEF) was independently associated with a high delta-ANP ratio (≥ 4.5 ANP value on the start date/ANP value at 6months; the mean value was used as the cutoff value) (odds ratio [OR]: 4.649, 95% CI 1.032-20.952 and OR: 7.558, 95% CI 1.427-40.042). The plasma level of ANP was increased, and the loop diuretic dose was decreased by the addition of neprilysin inhibitor therapy in patients with compensated HF. In patients with HFpEF and complicated persistent AF, neprilysin inhibitor therapy was associated with an increase in ANP.

Reverse Remodeling and Functional Improvement of Left Ventricle in Patients with Chronic Heart Failure Treated with Sacubitril/Valsartan: Comparison between Non-Ischemic and Ischemic Etiology.

Sacubitril/valsartan (SV) has been demonstrated to reduce cardiovascular mortality, hospitalization for heart failure and to induce reverse ventricular remodeling. The present study was designed to confirm the effects of SV in a selected population of patients with HFrEF and to evaluate the different responses between patients with an ischemic or a non-ischemic etiology. A total of 79 patients with indication of SV were recruited prospectively during a timelapse of 4 years. SV was overall associated to a reduction of end-diastolic and end-systolic volume, of NT-proBNP levels, furosemide dosage and NYHA functional class, together with an increase in EF. These changes were more evident in patients with non-ischemic dilated cardiomyopathy, who showed a significant improvement in ventricular volumes, ejection fraction, TAPSE and blood levels of NT-proBNP. Kaplan-Meier curves confirmed a greater benefit in terms of ejection-fraction improvement in non-ischemic patients compared to the ischemic group. The results of the present study confirm the positive effect of SV on NYHA functional class, NT- proBNP, left ventricular volumes and EF in HFrEF patients, showing evidence of association of SV with ventricular remodeling in patients with dilated cardiomyopathy of non-ischemic etiology compared to the ischemic group.

Natriuresis as a Way to Assess the Effectiveness of Diuretic Therapy for Acute Decompensated Heart Failure: Data from a Pilot Study

Aim. To analyze the clinical significance of the sodium level in a single urine test obtained 2 hours after the first dose of a loop diuretic was administered in patients with acute decompensation of chronic heart failure (ADHF).Material and methods. An observational study was conducted on the basis of a rapid-care hospital. The concentration of sodium in urine analysis obtained 2 hours after intravenous administration of the first dose of loop diuretic and natriuresis for the first day of hospitalization were evaluated. The development of resistance to diuretics was taken as the primary endpoint (the need to increase the daily dose of furosemide by more than 2 times compared to the initial one or the addition of another class of diuretic drugs).Results. 25 patients with ADHF were included. The average age of patients was 69.0±14.8 years, 16 (64%) of them were men. The average left ventricular ejection fraction was 49.0±13.5%. The level of the N‐terminal fragment of the brain natriuretic peptide (NT-proBNP) was 3416 (2128; 5781) pg/ml. The average sodium concentration in the urine analysis obtained 2 hours after the start of treatment was 100.6±41.0 mmol / l. The concentration of sodium in urine for the first day was 102.2±39.0 mmol/l. 2 hours after the start of treatment, the sodium concentration in a single urine test was less than 50 mmol/l in 5 (20%) patients. Upon further observation, oligoanuria (defined as diuresis of less than 400 ml within 24 hours) developed in 2 of them. Oligoanuria was not detected among patients whose sodium concentration was more than 50 mmol/l. The need for escalation (any increase in the dose of a loop diuretic and/or the addition of another class of diuretic drugs) arose in 7 (28%) patients; at the same time, we diagnosed the development of resistance to diuretics in 5 (20%) of them. Resistance to diuretics was more common among patients with a sodium concentration in a single urine test obtained 2 hours after the start of furosemide administration, less than 50 mmol/l (p=0.037); when dividing the recruited patient population into subgroups with a sodium concentration in a single urine test ≥50 mmol/l and &lt;50 mmol/l there was no significant difference in the need for any escalation of diuretic therapy [3 (60%) vs 4 (20%), p=0.07].Conclusion. Resistance to diuretics is more common among patients with a sodium concentration in a single urine test obtained 2 hours after the first dose of furosemide, less than 50 mmol / l. Evaluation of natriuresis allows to identify insufficient effectiveness of diuretic therapy already at the beginning of treatment.

PROFIL PENGGUNAAN OBAT PADA PASIEN STROKE ISKEMIK PADA PASIEN DI POLI NEUROLOGI

Background:Stroke is one of the main causes of mortality. WHO defines stroke as a spatial neurological disorder with sudden onset, lasting more than 24 hours without any cause and causing serious long-term disability in Indonesia and the United States. Objectives; This study aimed to determine the profile of ischemic stroke drugs usage in patients of Aceh Tamiang Hospital and the use of types of drugs given to ischemic stroke patients.Method; This study was non-experimental prospectively by using a questionnaire on ischemic stroke patients in October 2020. The data was processed using Microsoft Excel.Results; The results of 26 respondents and the drugs issued in October for the neurology clinic at Aceh Tamiang Hospital obtained antiplatelet drugs, namely aspirin 80mg/tab with a total of 238 drugs (38.3%) and pletaal 50mg/caplet with a total of 42 drugs (6.7%). The neuroprotectant group was pirassetam 80mg/tab with 140 drugs (22.5%). The antihyperlipidemic group of the drug simvastatin 5 mg/tab totaled 21 drugs (3.4%). The antihypertensive drug class was amlodipine 10mg/tab total 28 drugs (4.5%), amlodipine 5mg/tab total 56 drugs (8.9%), captopril drug type 25 mg/tab total 63 drugs (10.2%), the type of drug furosemide dose 40mg/tab the amount of 35 drugs (5.6%).Conclusion; Drugs that were widely used in patients with ischemic stroke are the antiplatelet group, namely aspirin 80mg/tab obtained 238 tablets (38.3%), the neuroprotectant class of the drug piracetam 800mg/cap were 140 caplets (22.5%), the antihypertensive group amlodipine 5mg/tab were 56 tablets (8.9%), the antihyperlipidemic group of the simvastatin 5mg/tab were 21 tablets (3.4%).&#x0D;

High furosemide doses are a strong marker of long-term mortality in heart failure (HF) outpatient

High furosemide doses are a strong marker of long-term mortality in heart failure (HF) outpatient

PENGARUH SUHU PENYEDUHAN TERHADAP EFEK DIURETIK TEH HIJAU PADA MENCIT JANTAN GALUR SWISS

Tea (Camelia sinensis L.) is a beverage that is familiar to the community and is drunk by brewing it. Green tea contains chemicals such as polyphenols, tannins, steroids and flavonoids. This study aimed to determine the effect of temperature brewing of green tea in the diuretic effect of male swiss strain mice. This research is an experimental study with 25 mice which were divided into five groups, group I (CMC Na 1%), Group II (Furosemide dose 5.2 mg/KgBB), Group III,IV and V (green tea brewed at 50oC,70oC dan 90oC ) with a brewing time of 5- 15 minutes. Urine measurements were performed every 1 hour for 6 hours. Data analysis was carried out using the One-Way ANOVA test followed by the LSD test with a 95% confidence level. The results showed that the diuretic effect at a brewing temperature of 50oC was not significantly different (p&gt; 0.05) with the diuretic effect at 70oC but the average volume of urine at 50oC was greater than 70oC. Diuretic effect at temperature 90oC was significantly different (p&lt;0.05) compared to 50oC and 70oC. The diuretic effect of green tea can be optimal, if the brewed at a temperature of 50oC and 70oC for 5-15 minutes

Predictors of bleeding events in acute decompensated heart failure patients with antithrombotic therapy: AURORA study.

Heart failure (HF) is reported to be one of the major risks of bleeding events. On the other hand, HF patients frequently receive anticoagulants or antiplatelet therapy to manage various co-morbidities. However, predictors of bleeding events in patients with HF have rarely been reported. This study aimed to evaluate the predictors of bleeding events and relationship between bleeding events and HF re-hospitalizations. We included 1660 acute decompensated heart failure (ADHF) patients from the AURORA registry between January 2015 and December 2020. A total of 1429 patients were excluded because of history of HF admission, missing echocardiographic data at discharge, lost to follow-up, haemodialysis and no antithrombotic drugs. Finally, we evaluated 231 patients from AURORA registry. The bleeding events were defined as Type 2 to 5 bleeding according to the Bleeding Academic Research Consortium definition. We divided our patients into the bleeding group and non-bleeding group. We compared the baseline characteristics, medications, laboratory data, and echocardiographic data between the two groups. Median age was 78 (IQR 71-82) years old and male accounted for 59%. Approximately half of the patients had an antiplatelet therapy and 70% had an anticoagulant therapy. During a median follow-up of 651 (IQR 357-1139) days, 32 patients (13.8%) suffered from bleeding events. The major driver of the registered events was gastrointestinal bleeding (n=21, 65.6%), and the other events were cerebral bleeding (n=4, 12.5%), intraarticular bleeding (n=2, 6.3%), urogenital bleeding (n=2, 6.3%), haemorrhagic pericardial effusions (n=1, 3.1%), subcutaneous hematomas (n=1, 3.1%), and haemothorax (n=1, 3.1%). There was a significantly lower haemoglobin level (P<0.01), higher proportion of inferior vena cava (IVC) diameter ≥21mm (P<0.01), and higher furosemide equivalent doses per kilogram (P<0.01) in the bleeding group than non-bleeding group. A multivariate analysis revealed an equivalent dose of furosemide per kilogram ≥0.66mg/kg (hazard ratios (HR) of 2.64, 95% confidence interval (CI) 1.26-5.68, P=0.01), haemoglobin ≤10.3g/dL (HR of 2.43, 95% CI 1.14-5.03, P=0.02), and IVC diameter ≥21mm (HR of 2.79, 95% CI 1.16-6.29, P=0.02) were independently associated with bleeding events. The Kaplan-Meier analysis showed that HF re-hospitalization rates were higher in the bleeding group than non-bleeding group (P=0.04). High doses of oral loop diuretics, IVC dilatation, and anaemia were predictors of bleeding events in patients hospitalized with ADHF patients. In addition, bleeding events were associated with HF re-hospitalizations.

Comparative effectiveness and safety of bolus vs. continuous infusion of loop diuretics: Results from the MIMIC-III Database

BackgroundIt is unclear whether fluid management goals are best achieved by bolus injection or continuous infusion of loop diuretics. In this study, we compared the effectiveness and safety of a continuous infusion with that of a bolus injection when an increased loop diuretic dosage is required in intensive care unit (ICU) patients. MethodsWe obtained data from the MIMIC-III database for patients who were first-time ICU admissions and required an increased diuretic dosage. Patients were excluded if they had an estimated glomerular filtration rate <15 ml/min/1.73 m2, were receiving renal replacement therapy, had a baseline systolic blood pressure <80 mmHg, or required a furosemide dose <120 mg. The patients were divided into a continuous group and a bolus group. Propensity score matching was used to balance patients’ background characteristics. ResultsThe final dataset included 807 patients (continuous group, n = 409; bolus group, n = 398). After propensity score matching, there were 253 patients in the bolus group and 231 in the continuous group. The 24 h urine output per 40 mg of furosemide was significantly greater in the continuous group than in the bolus group (234.66 ml [95% confidence interval (CI) 152.13–317.18, p < 0.01]). There was no significant between-group difference in the incidence of acute kidney injury (odds ratio 0.96, 95% CI 0.66–1.41, p = 0.85). ConclusionsOur results indicate that a continuous infusion of loop diuretics may be more effective than a bolus injection and does not increase the risk of acute kidney injury in patients who need an increased diuretic dosage in the ICU.

579 ACUTE ISCHEMIC HEART FAILURE: PHARMACOLOGICAL AND INTERVENTIONAL MANAGEMENT OF A FRAIL PATIENT

Abstract An 87-year-old male patient with worsening dyspnea was admitted to our institution. The patient had a history of acute myocardial infarction treated with coronary stenting of the left descending artery (LAD), diagonal (Diag), right coronary artery (RCA), and chronic kidney disease. For acute pulmonary edema, the patient was admitted to our cardiac intensive care unit and rapidly treated with non-invasive positive-pressure ventilation with continuous positive airway pressure (C-PAP), IV high dosage diuretic therapy, inotropes, and vasoactive agents. Chest X-ray revealed cardiomegaly (cardiothoracic ratio, 56%) and pulmonary congestion. Electrocardiogram revealed sinus tachycardia and diffuse ST-segment abnormalities. An echocardiogram demonstrated left ventricular apical akinesia, with a left ventricular ejection fraction (LVEF) of 25% and severe mitral regurgitation. Blood tests revealed very high levels of NT-pro-brain natriuretic peptide (NT-proBNP) (&amp;gt;30000 pg/ml) and myocardial necrosis markers (hs-Trop 5055 ng/l; CK-MB 72 ng/ml). After 24 hours, the patient was placed on intra-aortic balloon pump (IABP) support to further hemodynamic support through the right femoral artery, nonetheless, he showed no improvement in symptoms or urine output. Because of a state of hypoxemic and hypercapnic respiratory failure, non-invasive ventilation (NIV) was given to the patient with a gradual improvement in blood gas analysis. The optimization of diuretic therapy allowed to treat the state of acute oliguric kidney disease, avoiding dialytic treatment. After 48 hours, because of a new worsening in hemodynamic state, we decided for a percutaneous left ventricular assist device (Impella CP, Denver, Massachusetts, USA). After placing the Impella device, coronary angiography was performed, showing critical stenosis of the left main (LM), involving the origin of the left anterior descending artery and a collateralized chronic occlusion of the circumflex artery and the LAD, after the origin of a large first diagonal branch. Because of the high procedural risk, we decided to perform only percutaneous coronary intervention and stent implantation of LM. After 3 days his symptoms improved, the required dose of inotropic agents and furosemide decreased and Impella was removed. After 12 days the patient was admitted to the cardiological ward and discharged after 21 days because of a urinary infection requiring antibiotic therapy. The management of acute heart failure in very old patients is challenging, limiting in many cases the use of invasive procedures such as coronary angiography or left ventricular assist devices. In this case, although the patient presented a very high-risk profile considering age and comorbidities, the use of Impella resulted to be safe and guaranteed hemodynamic support during the procedure of revascularization and in the immediate post-operative phase.

Effects of Low-Dose Tolvaptan for Fluid Management After Cardiovascular Surgery.

Background: Perioperative management of body fluid levels after cardiovascular surgery with cardiopulmonary bypass is essential. Fluid management using tolvaptan with conventional diuretics is effective in maintaining urine output without worsening renal function. This study aimed to improve the in-out balance in the early perioperative phase using low-dose tolvaptan (3.75 mg/day). Methods and Results: This prospective, single-center, randomized, open-label study included 199 patients who underwent cardiovascular surgery with cardiopulmonary bypass in Kobe City Medical Center General Hospital between September 2018 and December 2020. Treatment with tolvaptan and loop diuretics (tolvaptan group; 99 patients) was compared with treatment with loop diuretics alone (control group; 100 patients) to evaluate achievement of preoperative body weight as the primary outcome. Secondary outcomes were urine volume, the incidence of worsening renal function (WRF), and postoperative paroxysmal atrial fibrillation (POAF). There was no significant difference between groups in the return to preoperative body weight on postoperative Day 6. The tolvaptan group had significantly increased urine volume (2,530 vs. 2,150 mL/day) and decreased total furosemide dose (24 vs. 32 mg) compared with the control group. No significant differences were observed in the development of WRF and POAF between the 2 groups. Conclusions: Although low-dose tolvaptan administration did not shorten the time to achieving preoperative body weight, it did significantly increase urine volume without WRF and POAF.

Early treatment with a sodium-glucose co-transporter 2 inhibitor in high-risk patients with acute heart failure: Rationale for and design of the EMPA-AHF trial

The aim of the EMPA-AHF trial is to clarify whether early initiation of a sodium-glucose co-transporter 2 inhibitor before clinical stabilization is safe and beneficial for patients with acute heart failure (AHF) who are at a high risk of adverse events. The EMPA-AHF trial is a randomized, double-blind, placebo-controlled, multicentre trial examining the efficacy and safety of early initiation of empagliflozin (10 mg once daily). In total, 500 patients admitted for AHF will be randomized 1:1 to either empagliflozin 10 mg daily or placebo at 47 sites in Japan. Study entry requires hospitalization for AHF with dyspnoea, signs of volume overload, elevated natriuretic peptide, and at least one of the following criteria: estimated glomerular filtration rate <60 mL/min/1.73 m2; already taking ≥40 mg of furosemide daily before hospitalization; and urine output of <300 mL within 2 hours after an adequate dose of intravenous furosemide. Patients will be randomized within 12 hours of hospital presentation, with treatment continued up to 90 days. The primary outcome is the clinical benefit of empagliflozin on the win ratio for a hierarchical composite endpoint consisting of death within 90 days, heart failure rehospitalization within 90 days, worsening heart failure during hospitalization, and urine output within 48 hours after treatment initiation. The EMPA-AHF trial is the first to evaluate the efficacy and safety of early initiation of empagliflozin in patients with AHF considered to be at high risk under conventional treatment.

Abstract 14354: Prognostic Impact of Low Serum Chloride Level in Elderly Patients With Heart Failure

Background: Patients with heart failure (HF) are known to be stratified the risk of mortality by serum chloride level. However, since large-scaled studies to date have not included the elderly patients, it is still unclear whether serum chloride level well predicts the prognosis of the elderly patients with HF, whose clinical profiles are different from young adult patients. We aimed to test the hypothesis that hypochloremia gave different prognostic impacts in non-elderly and elderly patients with HF. Methods: This observational study included 1,326 elderly patients ( &gt; 65 year-old) without regular hemodialysis who were hospitalized for worsening of HF and discharged alive. They were divided into two subgroups depending on serum chloride levels at admission (Low-chloride group ( &lt; 97 mEq/L, n=244); Normal-chloride group ( &gt; 98 mEq/L, n=1518)), referred to prior reports. Propensity scores were developed and patients in Normal-chloride group were matched with those in Low-chloride group in a 1:1 ratio. The endpoint of this study was death from any cause. Results: Among 1,326 unmatched patients, Low-chloride group included significantly more male patients, and those with higher BUN, CRP, bilirubin levels, dose of furosemide and atrial fibrillation, and prescriptions of oral anticoagulant, and lower BMI, blood pressure, hemoglobin, prescription of mineral corticoid receptor antagonist, thiazide and statins. Following propensity score matching by diverse baseline parameters, 106 pairs in both groups were included in the matched population. During 413 days of median observational period, 62 patients (28.8%) died. Kaplan-Meier analysis showed that patients in the Low-chloride group had a significantly higher mortality rate (p=0.011, Figure ). Conclusion: In this observational study, baseline hypochloremia was associated with an increased mortality in elderly patients hospitalized with heart failure.

PSUN264 Insulin Edema: A rare side effect of Intensive Insulin Therapy

Abstract Insulin therapy associated generalized edema is a rare entity. The true incidence is unknown. It has been reported mostly in patients with poorly controlled diabetes mellitus started on intensive insulin regimens. The severity ranges from mild lower extremity swelling to anasarca. Management is primarily supportive with salt restrictions, diuretics and if possible, reduction of insulin doses. We present a case of a 39-year-old African American woman who developed generalized edema after initiation of insulin. She had history of gestational diabetes and presented to the endocrinology clinic to establish care after being hospitalized with Diabetic Ketoacidosis (DKA). She was diagnosed with diabetes mellitus initially during her pregnancy two years prior and was treated with insulin. After pregnancy, she was lost to follow up. She was then admitted to the hospital with severe DKA and was discharged on multiple daily injections of insulin. On the initial encounter in clinic, the patient endorsed developing abdominal distension and lower extremity swelling with insulin use previously so she was not using insulin consistently. Her physical examination was unremarkable. Lab work was significant for hemoglobin A1C of &amp;gt;15%, C-peptide 0.9 ng/mL (1.1-4.4 ng/mL), islet cell antibody 0.09 nmol/L (&amp;lt;0.02 nmol/L), glutamic acid decarboxylase antibody 0.40 nmol/L (&amp;lt;0.02 nmol/L). Her kidney and liver function were normal. She had normal thyroid function and cortisol levels. Her echocardiogram revealed normal cardiac function and she had non proliferative diabetic retinopathy on retinal exam. The patient was started on insulin and a continuous glucose monitor was placed to assess her glycemic patterns. Three days after starting insulin, she developed generalized body swelling involving face, abdomen, and lower extremities. The patient was advised to cut back on salt and started on low dose furosemide. On follow up one month later, her abdominal swelling had improved however she still had pitting lower extremity edema. On follow up two months later the edema completely resolved. Clinicians should be aware of the presentation and management of insulin induced edema. In most of the cases in literature, insulin induced edema started after starting insulin in newly diagnosed Type 1 diabetes or uncontrolled Type 2 diabetes. The pathophysiology is unclear. There is some evidence that insulin deficiency causes a catabolic state and hyperglycemia increases tissue capillary permeability. Re-introduction of insulin causes free water retention and renal excretion of sodium. This along with increased capillary permeability can lead to insulin edema. Water retention caused by the effect of counter regulatory hormones can also play a role. Insulin edema needs to be differentiated from other causes of diffuse edema. Management is generally supportive including temporarily decreasing insulin doses, salt restriction and diuretics as needed. Patient reassurance is important as well to aid in adherence to the prescribed insulin regimen. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

A CASE OF AN UNRECOGNIZED AUTOINFLAMMATORY DISEASE

<h3>Introduction</h3> Yao syndrome is an auto-inflammatory disease involving mutations in the nucleotide-binding oligomerization domain 2 gene. We describe a case of a patient with Yao syndrome who remained undiagnosed for years. <h3>Case Description</h3> A 50-year-old Caucasian woman with history of Coronary Artery Disease s/p coronary artery bypass graft, Diastolic Heart Failure, Type II Diabetes Mellitus and Hypertension was referred to Immunology for evaluation of elevated ESR (58-107 mm/hr) and CRP (1.7-5 mg/dL). She had previously seen Hematology, Infectious Disease, Dermatology, Gastrointestinal Disease and Rheumatology who had ruled out autoimmune, malignancy or infectious etiologies. She reported a 20-30 year history of recurrent fevers, diffuse arthralgias involving both small and large joints with intermittent lower extremity swelling non responsive to high dose Furosemide, episodic abdominal pain, vomiting, diarrhea, recurrent maculopapular, erythematous rashes on face/extremities and dry mouth/dry eyes. A periodic fever panel was sent which showed a c.2798 +158C>T heterozygous mutation in the NOD2 gene. She was started on Canakinumab with improvement in her dermatitis, arthralgia, and GI symptoms with decreased CRP (0.4-0.5 mg/dL) and ESR (24-29 mm/hr). <h3>Discussion</h3> With a prevalence of 1 in 10,000-100,000, this is an uncommon but not rare disease to encounter. Yao Syndrome diagnosis requires 2 major criteria (periodic occurrence, recurrent fever or dermatitis), at least 1 minor criteria (polyarthralgia/distal extremity swelling, abdominal pain/diarrhea, sicca-like symptoms, pericarditis/pleuritis), molecular criteria (NOD2 IVS8+158 or R702W) and exclusion criteria (high ANA/IBD/Blau Syndrome/Sarcoid/Sjogren). This case illustrates the importance of considering auto-inflammatory disorders for periodic inflammatory symptoms and the necessity for genetic testing.

Retrospective evaluation of risk factors for development of kidney injury after parenteral furosemide treatment of left-sided congestive heart failure in dogs.

Kidney injury (KI) has been documented in dogs treated with furosemide for left-sided congestive heart failure (CHF). Determine risk factors for development of KI in furosemide-treated dogs and determine the effect of KI on survival. Seventy-nine client-owned dogs receiving parenteral furosemide for CHF. Serum creatinine (sCr) and electrolyte concentrations were determined during hospitalization and at first outpatient reevaluation to detect and stage KI (increase in sCr ≥0.3mg/dL). Furosemide dosage administered between timepoints was calculated. Multivariable modeling was performed to identify predictors of KI and percent change in serum biochemistry results over time. Kidney injury was identified in 38/79 (48%) dogs and mostly occurred during hospitalization. Kidney injury was Grade I in 25 dogs, Grade II in 9 dogs, and Grade III in 4 dogs. Higher blood pressure was associated with acute KI during hospitalization (odds ratio, 1.03; 95% confidence interval [95% CI] 1.01-1.07; P= .03) whereas PO furosemide dosage was associated with KI after hospital discharge (odds ratio, 7.77; 95% CI, 2.05-68.6; P= .02). Baseline sCr and use of a furosemide continuous rate infusion were not associated with increased risk of KI. Kidney injury was not associated with long-term outcome. Of 13 dogs with Grade II-III KI, azotemia was reversible in 9 dogs, and 6 dogs survived >1 year after KI. In this cohort of dogs receiving parenteral furosemide for CHF, KI was common, mostly nonazotemic (Grade I), and did not impact survival.

Relation between Mid-Regional Pro-Adrenomedullin in Patients with Chronic Heart Failure and the Dose of Diuretics in 2-Year Follow-Up-Data from FAR NHL Registry.

Background and Objectives: The aim of this paper is to evaluate the impact of humoral substance mid-regional pro-adrenomedullin (MR-proADM) on the two-year survival of patients with chronic heart failure and relate it to the dosage of furosemide. Materials and Methods: The data is taken from the stable systolic heart failure (EF < 50%) FAR NHL registry (FARmacology and NeuroHumoraL activation). The primary endpoint at two-year follow-up was death, heart transplantation, or LVAD implantation. Results: A total of 1088 patients were enrolled in the FAR NHL registry; MR-proADM levels were available for 569 of them. The mean age was 65 years, and 81% were male. The aetiology of HF was ischemic heart disease in 53% and dilated cardiomyopathy in 41% of patients. The mean EF was 31 ± 9%. Statistically significant differences (p < 0.001) were obtained in several parameters: patients with higher MR-proADM levels were older, rated higher in NYHA class, suffered more often from lower limb oedema, and had more comorbidities such as hypertension, atrial fibrillation, diabetes, and renal impairment. MR-proADM level was related to furosemide dose. Patients taking higher doses of diuretics had higher MR-proADM levels. The mean MR-proADM level without furosemide (n = 122) was 0.62 (±0.55) nmol/L, with low dose (n = 113) 1–39 mg/day was 0.67 (±0.30) nmol/L, with mid dose (n = 202) 40–79 mg/day was 0.72 (±0.34) nmol/L, with high dose (n = 58) 80–119 mg/day was 0.85 (±0.40) nmol/L, and with maximum dose (n = 74) ≥120 mg/day was 1.07 (±0.76) nmol/L, p < 0.001. Patients with higher MR-proADM levels were more likely to achieve the primary endpoint at a two-year follow-up (p < 0.001) according to multivariant analysis. Conclusions: Elevated plasma MR-proADM levels in patients with chronic heart failure are associated with an increased risk of death and hospitalization. Higher MR-proADM levels in combination with increased use of loop diuretics reflect residual congestion and are associated with a higher risk of severe disease progression.