Furosemide Infusion Research Articles

S3211 Weight Loss, Ascites, and Diarrhea as the Presenting Symptoms for Pseudo-Pseudo Meigs Syndrome

Introduction: Pseudo-pseudo Meigs syndrome (PPMS) is a rare presentation of systemic lupus erythematous (SLE) characterized by ascites, pleural effusion, and elevated CA-125 level. Case Description/Methods: A 30-year-old woman with SLE and history of small bowel obstruction presented with diarrhea, weight loss, anasarca, and alopecia. She was initially tachycardic and hypertensive. Her exam revealed profound anasarca with ascites and bilateral pleural effusions. Labs were notable for Cr=5.65 mg/dL (baseline 0.7 mg/dL), spot protein/creatinine=3.9, ferritin=554.6 ng/ml, ESR=145 mm/Hr, CRP=6 mm/Hr, C3=49 mg/dL, C4=19 mg/dL, unremarkable FSH and LH, +ANA, dsDNA 356 U/ml, and +pANCA/MPO. Outpatient workup showed elevated CA-125 to 260.8 U/mL but ovarian malignancy was ruled out by MRI and CT abdomen/pelvis. Transvaginal ultrasound was normal. Inflammatory bowel disease was ruled out by EGD and colonoscopy during a previous hospitalization. Renal ultrasound showed bilateral hydronephrosis. The patient underwent a paracentesis (SAAG 1.3), and thoracentesis that showed total serum protein 4.2 g/dl, pleural fluid LDH 67 U/L, no serum LDH or pleural protein available. Kidney biopsy demonstrated class IV / V lupus nephritis. She was treated with a three-day course of pulse dose methylprednisolone followed by prednisone, hydroxychloroquine, and furosemide infusion. Her symptoms mostly resolved and CA-125 trended down to 27 U/mL. Discussion: PPMS is a rare condition with few cases reported in the literature. This case illustrates the challenges of evaluating abdominal symptoms and ascites in patients with SLE, and the importance of a kidney biopsy in the evaluation of nephrotic range proteinuria. Due to infrequency and concern for malignancy due to elevated CA-125 level, patients with this syndrome undergo extensive workup. CA-125 has been shown to be elevated due to inflammatory markers enhancing its expression in peritoneal mesothelial cells. Prior publications have shown the correlation of CA-125 with extent of serositis in PPMS. Additionally, our patient has many other clinical features reported in PPMS patients including elevated ferritin, alopecia, and positive pANCA. CT scan of abdomen and pelvis is essential in the workup of this syndrome to rule out ovarian malignancy. Moreover, imaging may exclude mesenteric vasculitis, an uncommon feature of SLE which can be seen as targetoid lesions of the bowel on CT scan. Steroids are the treatment for PPMS.

Response Guided Slow Infusion of Albumin, Vasoconstrictors and Furosemide Improves Ascites Mobilization and Survival in Acute on Chronic Liver Failure: A Proof-of-Concept Study.

Background and AimsAcute-on-chronic liver failure (ACLF) with increasing organ failure is associated with poor outcomes. Severely deranged systemic hemodynamics and decreased effective arterial blood volume contribute to tissue damage and organ failure. Response-guided therapy with albumin, vasoconstrictors, and furosemide may help overcome effective hypovolemia, improve diuresis and impact survival.MethodsIn the observation cohort, 230 patients with ACLF (CANONIC criteria) with ascites (≥Grade II) and ACLF ≥Grade I were enrolled. A total of 136 patients (GROUP I) received response-guided (urine sodium >80mmol/day) slow albumin-furosemide infusion ± terlipressin (SAFI ± T), while 94 patients (GROUP II) received standard medical therapy. Twenty-eight-day survival, ascites mobilization (nil or grade 1), and adverse events were noted. In another mechanistic cohort (n = 40), laboratory evidences for improvement in various pathophysiological alterations; gut permeability, endotoxemia, cytokine storm, neutrophil dysfunction, and hemodynamic alterations following SAFI ± T/Noradrenaline (NAdr) were evaluated.ResultsAge, gender, CLIF-C-ACLF, SOFA and MELD scores, ACLF grades and urine sodium were not different between the two groups in the observation cohort. Ascites was mobilized in 102/136 in GROUP I (SAFI ± T) and 23/94 in GROUP II (p < 0.05). Twenty-eight-day survival was significantly higher in GROUP I = 103/136 (75.7%) vs GROUP II = 50/94 (53.2%), (P = <0.001). All those who were unable to reach urine sodium >80 mmol/day died. Four patients in GROUP I developed scrotal gangrene. In the mechanistic cohort, 72% of patients survived with significant improvement in gut permeability, endotoxemia, serum cytokines, neutrophil dysfunction, and hemodynamic alterations.ConclusionAscitic fluid mobilization by response-guided SAFI ± T/NAdr therapy improves survival by improving splanchnic and systemic hemodynamics, decreasing gut congestion, gut permeability, and endotoxemia, improving neutrophil functions, and reducing pro-inflammatory cytokines in circulation.

Comparison of Different Furosemide Regimens in the Treatment of Acute Heart Failure: A Meta-Analysis.

Background To compare the effects of different dosing schemes of furosemide on acute heart failure (AHF). Methods Literature that compared the efficacy of continuous and intermittent administration of furosemide in AHF patients was retrieved from PubMed, Embase, the Cochrane Library, and ISI Web of Science from inception to May 2022. The primary endpoints included overall weight loss, 24-hour urine volume, length of hospital stay, 24-hour brain natriuretic peptide (BNP) level change, and all-cause mortality. The RevmMan5.4 software was used to analyze the extracted data. Results A total of 10 studies with 775 patients, including 338 receiving continuous furosemide administration and 387 receiving intermittent furosemide administration, were included. The analysis results showed significant differences in weight loss (MD = 1.08, 95% CI (0.75~1.40), P < 0.00001) and 24-hour urine volume (MD =335.23, 95% CI (140.98~529.47), P = 0.0007) between the 2 groups. There was no significant difference in terms of length of hospital stay (MD = −0.71, 95% CI (-2.74~1.31), P = 0.49) and all-cause mortality (RR = 1.59, 95% CI (0.92~2.75), P = 0.10). Conclusions Compared with intermittent administration, continuous infusion of furosemide had a significant effect on the 24-hour urine volume and total weight loss in patients with AHF.

The Application of Dopamine Combined with Intravenous Furosemide Infusion Therapy Has an Apparent Clinical Effect in Treating Patients with Heart Failure.

Objective To observe the efficacy and safety of dopamine plus furosemide in treating patients with heart failure. Methods This research included 150 patients with heart failure who were diagnosed and treated at our hospital between March 2018 and November 2020. The patients were randomly assigned to a study group or a reference group according to the data of admission (the cut-off date was June 2019). Patients in the reference group were given furosemide, whereas those in the study group were given dopamine plus furosemide intravenous pumping. Outcome measures included clinical effectiveness, heart function changes, and adverse responses. Results Dopamine plus furosemide resulted in higher treatment efficiency (96.00%) versus furosemide (74.67%) study group (P < 0.05). Before therapy, there was no significant change in the scores of cardiac function indices between the two groups (P > 0.05). The cardiac function of the two groups of patients was improved after treatment, and the left ventricular ejection fraction (LVEF) of the study group (44.85 ± 4.12) was higher than that of the reference group (38.45 ± 4.36), and the left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic diameter (LVESD), and plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP) (43.17 ± 3.98, 51.32 ± 4.25, 3045.56 ± 365.48) were lower than the reference group (47.56 ± 4.65, 56.28 ± 4.85, 4856.48 ± 395.46) (P < 0.05). There was no significant difference in the total incidence of adverse reactions between the two groups (P > 0.05). Conclusion Dopamine plus intravenous furosemide infusion treatment has an obvious therapeutic benefit in treating patients with heart failure and dramatically enhances cardiac function without noteworthy adverse responses. It demonstrated great potential for clinical promotion.

Multimodal Strategies for the Diagnosis and Management of Refractory Congestion. An Integrated Cardiorenal Approach.

Refractory congestion is common in acute and chronic heart failure, and it significantly impacts functional class, renal function, hospital admissions, and survival. In this paper, the pathophysiological mechanisms involved in cardiorenal syndrome and the interplay between heart failure and chronic kidney disease are reviewed. Although the physical exam remains key in identifying congestion, new tools such as biomarkers or lung, vascular, and renal ultrasound are currently being used to detect subclinical forms and can potentially impact its management. Thus, an integrated multimodal diagnostic algorithm is proposed. There are several strategies for treating congestion, although data on their efficacy are scarce and have not been validated. Herein, we review the optimal use and monitorization of different diuretic types, administration route, dose titration using urinary volume and natriuresis, and a sequential diuretic scheme to achieve a multitargeted nephron blockade, common adverse events, and how to manage them. In addition, we discuss alternative strategies such as subcutaneous furosemide, hypertonic saline, and albumin infusions and the available evidence of their role in congestion management. We also discuss the use of extracorporeal therapies, such as ultrafiltration, peritoneal dialysis, or conventional hemodialysis, in patients with normal or impaired renal function. This review results from a multidisciplinary view involving both nephrologists and cardiologists.

Neurogenic stunned myocardium resulting from surgical brainstem handling during resection of paediatric recurrent medulloblastoma—a possible brain heart interaction

Neurogenic stunned myocardium (NSM) is characterised by an acute onset cardiac dysfunction following an acute neurological insult which mimics acute coronary syndrome. A 12-year-old male child was admitted to the neuro-intensive care unit (NICU) following midline suboccipital craniotomy and resection of recurrent medulloblastoma. Postoperatively, in NICU, he developed tachycardia and hypotension, which was unresponsive to fluid challenge requiring norepinephrine infusion. Intraoperatively, during tumour resection from the dorsal medulla, episodes of hypertension and bradycardia were observed. Intraoperative blood loss was adequately managed with a stable hemodynamic profile without postoperative anaemia. An electrocardiogram showed sinus tachycardia with T wave inversion, and blood investigation revealed elevated cardiac troponin T levels. Point of care ultrasound (POCUS) of heart and lung showed features of NSM. Infusion dobutamine was added to achieve a target mean arterial pressure of 65mm Hg with concomitant furosemide infusion and fluid restriction. Daily POCUS assessment of cardiac contractility and volume status was done. The patient was weaned from vasoactive drugs and ventilator following improvement of cardiac function and was discharged from NICU after 17days. NSM results from the excessive release of catecholamines following stimulation of trigger zones in the brain. To date, a handful of cases of pediatric NSM following primary brain tumour are reported where hydrocephalus resulted in trigger zone activation. In this presented case, direct brain stem stimulation during tumour resection might have triggered NSM. Irrespective of the cause, timely diagnosis and execution of supportive management in our patient resulted in a positive outcome.

The effect of active diuretic therapy on the sodium balance in patients with acute decompensation of chronic heart failure

Background. Active dehydration of patients with acute decompensation of chronic heart failure (АDCHF) was often accompanied by the development of hyponatremia. This increased the time of hospitalization and worsened the prognosis. The complication was associated with the side effects of furosemide.&#x0D; Aim. To compare the effect of dehydration and the state of sodium balance after using different methods of parenteral administration of furosemide at an early stage of treatment of АDCHF.&#x0D; Materials and methods. Patients with АDCHF (n=125) were divided into two groups. Group 1 received furosemide as bolus injections, group 2 as an extended intravenous infusion. The process of dehydration was controlled by the amount of urine and body weight loss per day. The effect was considered satisfactory if the body weight decreased by 1.02.0 kg per day. The plasma sodium level was studied on 1, 5, 10 days.&#x0D; Results. In group 2, the satisfactory effect of dehydration was observed 1.7 times more often than in group 1 (p0.05). In group 2 patients on the 5th day of therapy, the number of cases of hyponatremia was 2.3 times less (p0.05). Hyponatremia developed little in patients with a satisfactory effect of dehydration. On the 10th day, the number of cases of hyponatremia in the groups did not significantly differ.&#x0D; Conclusion. Prolonged intravenous infusion of furosemide allowed more control of the dehydration process and the plasma sodium level at an early stage of therapy in patients with АDCHF.

The Effect in Renal Function and Vascular Decongestion in Type 1 Cardiorenal Syndrome Treated with Two Strategies of Diuretics, a Pilot Randomized Trial

AimThe main treatment strategy in type 1 cardiorenal syndrome (CRS1) is vascular decongestion. It is probable that sequential blockage of the renal tubule with combined diuretics (CD) will obtain similar benefits compared with stepped-dose furosemide (SF).MethodsIn a pilot double-blind randomized controlled trial of CRS1 patients were allocated in a 1:1 fashion to SF or CD. The SF group received a continuous infusion of furosemide 100 mg during the first day, with daily incremental doses to 200 mg, 300 mg and 400 mg. The CD group received a combination of diuretics, including 4 consecutive days of oral chlorthalidone 50 mg, spironolactone 50 mg and infusion of furosemide 100 mg. The objectives were to assess renal function recovery and variables associated with vascular decongestion.ResultsFrom July 2017 to February 2020, 80 patients were randomized, 40 to the SF and 40 to the CD group. Groups were similar at baseline and had several very high-risk features. Their mean age was 59 ± 14.5 years, there were 37 men (46.2%). The primary endpoint occurred in 20% of the SF group and 15.2% of the DC group (p = 0.49). All secondary and exploratory endpoints were similar between groups. Adverse events occurred frequently (85%) with no differences between groups (p = 0.53).ConclusionIn patients with CRS1 and a high risk of resistance to diuretics, the use of CD compared to SF offers the same results in renal recovery, diuresis, vascular decongestion and adverse events, and it can be considered an alternative treatment. ClinicalTrials.gov with number NCT04393493 on 19/05/2020 retrospectively registered.

Efficacy and Safety of Subcutaneous Infusion of Non-formulated Furosemide in Patients with Worsening Heart Failure: a Real-World Study

We aimed to evaluate the efficacy (short-term changes in surrogates of decongestion) and safety following the ambulatory administration of subcutaneous furosemide (SCF) in patients with WHF. Fifty-five ambulatory patients were treated with SCF administered by an elastomeric pump for at least 72 h. Surrogates of congestion were assessed at baseline, 72 h, and 30 days. Spot urinary sodium (uNa+) was assessed at baseline, 24-48-72 h, and 30 days. The median (IQI) of NT-proBNP and uNa+ at baseline was 5218 pg/mL (2856-10878) and 68±3 mmol/L, respectively. Following administration of SCF (median dose of 100 mg/daily), we found a sustained increase in uNa+ during the first 72 h of treatment compared to baseline, paralleled with evidence of decongestion at 72 h, and 30 days. No significant safety concerns were observed. SCF was an effective and safe diuretic strategy for outpatient congestion management.Graphical abstractNon-formulated subcutaneous furosemide in patients with WHF. Efficacy and safety.

Use of Furosemide and Chlorothiazide Combination Continuous Infusion in Furosemide-Refractory Patients in the Pediatric Intensive Care Unit: A Retrospective Cohort Study.

Our objective was to describe the efficacy and safety of furosemide and chlorothiazide combination continuous infusion (FCCCI) in children in a pediatric intensive care unit (ICU), including postoperative cardiac patients. This was a retrospective cohort study in a pediatric ICU within a tertiary care teaching hospital. Children aged < 18 years admitted from 1 January 2010 to 31 December 2019 were included if they received a furosemide infusion for at least 6 h and then transitioned to FCCCI. Each patient acted as their own control. A total of 203 patients (107 [53%] postoperative cardiac) met the study inclusion criteria. The study population was 55% male and 74% Caucasian, with a median age of 4.9 months. Of the total patients, 143 (70.4%) required mechanical ventilation and 39 (19.2%) required dialysis. The median duration of furosemide and FCCCI was 24.6 h (interquartile range [IQR] 12.4-54) and 41 h (IQR 15-162), respectively. Urine output increased by 52% with FCCCI (mean increase of 2.2 mL/kg/h [95% confidence interval {CI} 1.8-2.5]; p<0.01). The change to FCCCI led to a net negative daily fluid balance (mean difference -301.9 mL/day [95% CI -390.9 to -212.9]; p<0.01). FCCCI resulted in a greater requirement for potassium bolus supplementation (mean increase of 12.8 boluses [95% CI 8.5-17.2]; p<0.01) and a small but statistically significant increase in serum creatinine (mean difference 0.1 mg/dL [95% CI 0.06-0.14]; p<0.01) with a resultant decrease in estimated glomerular filtration rate (mean difference -13.5 [95% CI 9.7-17.4]; p<0.01). Of the furosemide-refractory patients, 78.9% were responsive to FCCCI. Younger patients and patients who underwent cardiothoracic surgery were more likely to be responsive. Nonresponders to FCCCI had slightly higher mortality (21 vs. 6.6%, p = 0.05). FCCCI resulted in a significant improvement in diuresis with achievement of negative fluid balance in pediatric ICU patients. FCCCI is a reasonable approach to aggressive diuresis in the pediatric patient, particularly in patients with limited access. Serum potassium should be routinely monitored during such therapy.

Comparison of continuous infusion and intermittent boluses of furosemide in acute heart failure: A protocol for systematic review and meta-analysis.

Background:Acute heart failure (HF) is a common cause of hospital admission. This study aims to compare continuous infusion and intermittent boluses of furosemide in treating acute HF.Methods:This protocol of systematic review and meta-analysis has been drafted under the guidance of the preferred reporting items for systematic reviews and meta-analyses protocols. Electronic databases including Web of Science, Embase, PubMed, Wanfang, Data, Scopus, Science Direct, and Cochrane Library will be searched in June 2021 by 2 independent reviewers. The main outcomes are post-treatment daily urine output, weight, length of stay, serum sodium, potassium, and creatinine. Two researchers conducted a quality assessment in strict accordance with the risk bias assessment tool recommended by the Cochrane Handbook Version5.3. We performed the meta-analysis by Stata version 10.0 software.Results:The results of this systematic review and meta-analysis will be published in a peer-reviewed journal.Conclusion:The choice of furosemide regime in acute HF remains physician preference. Both bolus and continuous infusion yields satisfactory outcomes.

A life-threatening case of pseudo-aldosteronism secondary to excessive liquorice ingestion

BackgroundLiquorice is found in many food products, soft drinks, and herbal medicines. Liquorice ingestion is an uncommon cause of apparent mineralocorticoid excess or pseudo-aldosteronism. The mechanism involves the inhibition of 11-beta-hydroxysteroid dehydrogenase type-2 by the active ingredient called glycyrrhizin. This leads to the uninhibited activation of mineralocorticoid receptors by cortisol. Confectionary products that contain liquorice are readily available in many countries around the world.Case presentationWe report a case of severe refractory hypokalaemia with hypertensive crisis and acute pulmonary oedema due to excessive liquorice consumption. A 79-year-old female presented to the emergency department following a road traffic accident. She described feeling weak and dizzy while driving before the collision. She attended her general practitioner (GP) several weeks earlier for fatigue and was being managed for hypokalaemia on oral potassium supplements. Investigations revealed hypertension (BP 180/69 mmHg), severe hypokalaemia (K 2.2 mmol/l), normal renal function, normal serum magnesium with metabolic alkalosis. Spot urinary potassium was 22 mmol/l. The patient denied taking medications including over-the-counter or herbal medication that can cause hypokalaemia. Hypokalaemia persisted despite aggressive intravenous (i.v.) and oral potassium replacement. She later developed a hypertensive crisis (BP 239/114 mmHg) with pulmonary oedema. She required admission to the intensive care unit and was managed with intravenous furosemide infusion and isosorbide dinitrate infusion. On further discussion, our patient admitted to struggling with nicotine cravings since quitting smoking two months earlier. She began eating an excessive amount of liquorice sweets to manage her cravings. Suppression of plasma renin and aldosterone supported the diagnosis of apparent mineralocorticoid excess secondary to excessive liquorice consumption. Her symptoms and hypokalaemia resolved after stopping liquorice intake.ConclusionsThis case highlights the life-threatening and refractory nature of hypokalaemia secondary to excessive liquorice consumption. This case also emphasizes the importance of comprehensive history taking including dietary habits. Increased awareness among the public is required regarding the potential health hazards of excessive liquorice consumption.

MO234LIFE THREATENING MALIGNANT HYPERCALCEMIA IN BREAST CANCER: CAN THE NEPHROLOGIST CHANGE THE PATIENT DESTINY?

Abstract Background Malignant hypercalcemia is a common complication in cancer patients and can be predictive of poor prognosis and advanced malignancy. Cancer-related mechanisms of hypercalcemia depends either on ectopic hypersecretion of humoral factors (PTH, PTH-like molecules, Vit D) by the tumoral mass, or on osteolysis due to bone invasion. In consideration of the high renal and cardiac impact of severe hypercalcemia, its prompt recognition and treatment can be lifesaving. AKI is frequently associated with malignant hypercalcemia and recognizes a multifactorial pathogenesis (direct renal vasoconstriction, volume depletion, tubule-interstitial damage, etc.). Substitutive renal treatment can be necessary, but not always viable in patients with poor physical performance and is a difficult choice in cancer patients with advanced malignancies. Case report We present the case of a 46 years old woman with an infiltrating non special type (NST) carcinoma of the right breast (luminal B, ER 70%, PgR 60%, Ki67 35%, HER2 1+). Unfortunately, she quickly progressed after a neoadjuvant treatment with Epirubicin/Cyclophosfamide (4 cycles) followed by Paclitaxel (10 cycles). A first line hormonal treatment (Palbociclib, Letrozole and LHRH analogous) was then started, but a further rapid disease progression was observed. A new biopsy showed a muted and more aggressive cancer phenotype (high grade triple negative carcinoma with no PDL1 expression). Due to a rapid worsening of general conditions with cognitive impairment, the patient was admitted to the Oncology department. Blood test showed severe hypercalcemia (corrected calcium: 23.26 mg/dl) and severe hypokalemic metabolic alkalosis (blood pH 7.57; HCO-3 32 mmol/l; K+ 2.6 mmol/l) associated to AKI (creatinine doubled to 1.42 mg/dl; eGFR 45 ml/min/1,73 mq). Alkaline phosphatase and Vitamin D were normal and iPTH was &amp;lt; 2 pg/ml. ECG showed a significant QTc prolongation to 550 msec. Imaging exams revealed lung metastasis, lung carcinomatous lymphangitis and bilateral pleural effusion, while Bone Scan showed a low caption limited to right ribs. Oncologists and Intensive Care Physicians referred to our Nephrology and Dialysis Unit proposing Hemodialysis support. In consideration of the preserved diuresis, the advanced disease stage and the unstable hemodynamics, our advice was instead for a conservative medical approach. An i.v. infusion of 4000 ml NaCl 0.9% + KCl 60 mEq/24h; a continuous i.v. infusion of Furosemide 5mg/h were started and maintained for several days, leading to a progressive and full renal function recovery (creatinine decreased to 0.7 mg/dl) and metabolic alkalosis correction. However, corrected calcium remained largely over target, being 16.3 mg/dl. Sodium bicarbonate 80 mEq, Zoledronic acid 4 mg and Desametasone 4mg/day were administered and at day 16 even calcium was in normal range. We realized that this was a favourable window for acting on the underlaying cause of malignant hypercalcemia, that likely was the aberrant secretion of non-dosable PTH-like molecule(s). Thus, we suggested the Oncologist to start chemotherapy, and they were allowed to treat the patient with Carboplatin/Gemcitabine. The patient was successfully treated with stabilization of normocalcemia and is still alive. Conclusion Malignant hypercalcemia is a life-threatening complication in advanced malignancies. Our case report highlights the key role of the nephrologist in treating a complex and fragile oncologic patient, achieving the full correction of several severe renal disorders, hemodialysis avoidance and survival improvement.

A Study on Continuous Infusion versus Intermittent bolus dosing of Furosemide in Hospitalized Heart failure patients

Introduction: Intravenous loop diuretics is one of the cornerstone therapy of heart failure patients presenting with congestion, however the optimal dosage and administration strategies remain poorly defined. We intended to evaluate the differences between the two administration routes based on the efficacy and the renal functions. Methods: Sixty patients with heart failure admitted in the critical care medicine were initially enrolled in the study. Four patients were excluded due to eGFR&lt;15ml/min. The remaining 28 patients in each group (Group I: continuous furosemide infusion (cIV) and Group II: intermittent furosemide bolus injections (iIV) i.e., three equal intermittent daily doses) were administered with Inj. Furosemide (120mg/day). All patients were daily evaluated for NYHA class, urine output, serum electrolytes, BNP, and renal parameters. Results: The efficacy of the either group of intravenous administration were evaluated using the following end points such as cumulative urine output (2,505±796 vs 2140±468 ml/day, p &lt; 0.04), serum creatinine levels, B.U.N levels, G.F.R and BNP levels. 56 patients were studied with 28 in each group. The c1V group showed an increase in urine output and a more significant decrease in the BNP levels when compared to the bolus. We observed a significant difference in GFR (p&lt;0.05), creatinine (p&lt;0.01) and B.U.N (p&lt;0.05) from baseline to the end of treatment in both the groups. Conclusion: The administration of intermittent furosemide bolus injection (iIV) is better than continuous furosemide infusion (c1V). Theoretically, cIV appeared to provide more efficient gradual diuresis with less neurohormonal activation, however it was also associated with increased rate of worsening renal function during hospitalisation.

Trial of Furosemide to Prevent Acute Kidney Injury in Critically Ill Children: A Double-Blind, Randomized, Controlled Trial.

ObjectiveTo study whether furosemide infusion in early-onset acute kidney injury (AKI) in critically ill children would be associated with a reduced proportion of patients progressing to the higher stage (Injury or Failure) as compared to placebo.MethodA double-blind, placebo-controlled, randomized pilot trial was conducted. The authors enrolled children aged 1-mo (corrected) to 12-y, who were diagnosed with AKI (“risk” stage) using pediatric-Risk, Injury, Failure, Loss, End stage kidney disease (p-RIFLE) criteria, and achieved immediate resuscitation goals within 24 h of admission. Participants received either furosemide (0.05 to 0.4 mg/kg/h) or placebo (5%-dextrose) infusion. The primary outcome was the proportion of patients progressing to a higher stage (injury or failure). Secondary outcomes were (i) need for renal replacement therapy, (ii) the effect on neutrophil gelatinase-associated lipocalin (urine and blood), (iii) fluid balance, (iv) adverse effects, (v) time to achieve renal recovery, (vi) duration of hospital stay and mechanical ventilation, and (vii) all-cause 28-d mortality.ResultsThe trial was stopped for futility, and data were analyzed on an intention-to-treat basis (furosemide-group: n = 38; placebo-group: n = 37). No significant difference was noted in the progression of AKI to a higher stage between furosemide and placebo groups (10.5% vs. 21.6%; relative risk = 0.49, 95% CI 0.16 to 1.48) (p = 0.22). There were no differences in the secondary outcomes between the study groups. All-cause 28-d mortality was similar between the groups (10.5% vs. 10.8%). No trial-related severe adverse events occurred.ConclusionsFurosemide infusion in early-onset AKI did not reduce the progression to a higher stage of AKI. A future trial with large sample size is warranted.

Insuficiência Cardíaca Crónica em Hospitalização Domiciliária

INTRODUÇÃO: A insuficiência cardíaca crónica é considerada, a nível mundial, a principal causa de internamento em doentes com idade superior a 65 anos. A Unidade de Hospitalização Domiciliária (UHD) foi criada com o objetivo de minimizar as complicações hospitalares, proporcionar maior qualidade de vida e atingir melhores resultados funcionais.MATERIAL E MÉTODOS: Estudo retrospetivo de um ano de hospitalização domiciliária da Unidade Local de Saúde de Castelo Branco, destacando apenas doentes internados por descompensação da insuficiência cardíaca crónica.RESULTADOS: Neste período foram internados 99 doentes, 23,3% por descompensação da insuficiência cardíaca crónica. Eram do sexo masculino, 52,1%. A idade média foi de 79,8 anos (±10,6). O tempo médio de internamento foi de 6,7 dias (±3). As principais causas da insuficiência cardíaca foram: hipertensão arterial (43,4%) e arritmias (30,4%). O principal fator de descompensação foi infeções (69,5%). Estiveram sob perfusão inicial de furosemida, 56,5%. Evoluíram favoravelmente 95,6% (n=22) dos doentes e 4,3% (n=1) foi transferido para o internamento convencional. Segundo a escala de NEWS, 7,9%-12,7% dos doentes tinham risco de serem admitidos em unidade de cuidados intermédios/intensivos ou morrer entre 60 dias. O índice de comorbilidades de Charlson foi de 3-10 pontos e a sobrevivência num período de 10 anos estimava-se em 0%-77%. Noventa dias após a alta, 69,5% não regressaram à urgência nem foram reinternados.CONCLUSÃO: A hospitalização domiciliária em doentes com insuficiência cardíaca é vantajosa por proporcionar maior conforto ao doente e reduzir as complicações. Estudos demonstraram que a hospitalização domiciliária aumentou o tempo entre as readmissões, melhorou a qualidade de vida dos doentes e reduziu os custos das hospitalizações.

Femoral Vein Pulsatility: What Does It Mean?

In this report, the clinical evolution of a 72-year-old patient transferred to the surgical intensive care unit after cardiac surgery is described. The presence of a pulsatile Doppler signal of the common femoral vein was noted after surgery. On postoperative day 5, diuretics in addition to a combination of inhaled epoprostenol and milrinone were associated with normalization of femoral vein pulsatility. The observations seen in peripheral venous flow reinforce the hypothesis that pulsatility of the common femoral vein represents an associated echocardiographic sign of right ventricular dysfunction and may be used to monitor systemic venous congestion. Pulsatility in the venous system may be improved by reducing volume overload and improving right ventricular function.

Continuous versus intermittent use of furosemide in patients with heart failure and moderate chronic renal dysfunction.

AimsThere is paucity of clinical data comparing continuous infusion (CI) with bolus injection (BI) of intravenous loop diuretics in patients with acute decompensated heart failure (ADHF) and chronic renal dysfunction. This study aimed to compare the efficacy and safety of CI versus BI intravenous furosemide administration in patients with ADHF and moderate chronic renal insufficiency.Methods and resultsAcute decompensated heart failure and moderate chronic renal insufficiency [with estimated glomerular filtration rate (eGFR) 15.0–44.9 mL/min/1.73 m2] were randomized to start intravenous furosemide by BI or by a 6 h CI. End points included freedom from congestion at 72 h, the degree of dyspnoea assessed using the 0–10 Borg's category ratio scale, net daily urine output, weight loss during the study, length of hospital stay, total urinary sodium excretion, and development of acute kidney injury or electrolyte disturbance. After 72 h of treatment, the rate of the primary endpoint of freedom from congestion in the CI group was significantly higher than that in the BI group (69.05% vs. 43.59%, P = 0.02). The modified Borg scale indicated patients in the CI group had lower dyspnoea score than those in the BI group at 48 h (4.29 ± 1.23 vs. 5.97 ± 1.56; P = 0.02) and 72 h (1.15 ± 0.35 vs. 2.66 ± 0.83; P = 0.003). There were other significant differences favouring the CI group with regard to net urine output at 72 h (5145.98 ± 621.37 mL vs. 3755.95 ± 456.93 mL; P = 0.007), the mean body weight loss (4.72 ± 1.01 kg vs. 3.53 ± 0.73 kg; P = 0.02) and the total urinary sodium excretion (385.05 ± 38.15 vs. 320.33 ± 37.67; P = 0.02). The length of hospitalization in the CI group was significantly shorter than that in the BI group (10.36 ± 4.20 days vs. 15.68 ± 6.15 days; P = 0.02). No significant differences were observed between groups in the frequency of acute kidney injury, tinnitus, electrolyte disturbance or mortality.ConclusionsContinuous intravenous infusion of furosemide resulted in significantly greater diuresis than bolus administration of an equal dose in patients with moderate chronic renal insufficiency and ADHF, while no differences emerged in terms of side effects or mortality.

Right-Sided Heart Failure Presentation in Severe Valvular Aortic Stenosis: How to Deal with Diuretic Use?

BACKGROUND: Patients with right-sided heart failure and severe aortic stenosis (AS) have many clinical challenges to overcome fluid retention. Typical diuretic therapeutic approach can be recommended for the guidance of removing fluid overload in severe AS with right ventricular (RV) failure. The aim of this case review is to understand how to assess and manage RHF and severe AS. CASE SUMMARY: A 65-year-old female with worsening bilateral leg swelling and she aware of shortness of breath for 3 months. Physical examination revealed a grade 3/6 ejection systolic murmur at the aortic area radiating to the neck, a grade 2/6 diastolic murmur at the pulmonic area, and a grade 3/6 systolic murmur at the apex radiating to the axilla, increased jugular venous pressure, prominent bilateral leg swelling, and minimal rhonci at the base of the lungs. The chest X-ray showed worsening cardiomegaly in the last 3 months. Echocardiography revealed high gradient severe valvular AS, decreased systolic RV function, and other valvular dysfunctions including moderate mitral regurgitation, moderate pulmonary regurgitation, and mild tricuspid regurgitation. She was introduced high dose furosemide infusion. The average urine output production was 5 L/day and negative fluid balance was 3 L/day. Furosemide dose was adjusted daily according to urine output production and she was discharged after 6 days hospitalization. DISCUSSION: This case report provides an example of RV failure in severe AS patient. Hemodynamic monitoring and typical approach of diuretic therapies should be needed in the management of fluid overload in severe AS. KEYWORDS: right-sided heart failure, severe aortic stenosis, diuretic.

Adjunct Hypertonic Saline in Patients with Diffuse Edema Due to Heart Failure: A Randomized Double-Blinded Clinical Trial.

In patients with diuretic resistance due to heart failure, higher doses or continuous furosemide infusion and adding hypertonic saline solution (HSS) to diuretics could be effective. The goal of this study was to assess the effectiveness of hypertonic saline solution administration in weight loss of hospitalized patients with diuretic-resistant edema due to heart failure. In a randomized double-blinded clinical trial, adult patients with diffuse peripheral edema due to heart failure who were unresponsive to 80 mg of oral furosemide were enrolled. The patients were randomized into two groups. In the intervention and control groups, patients received 150 mL of HSS and normal saline, respectively. Subjects in both groups received 250 mg IV furosemide every 12 h for 48 h. The change in body weight, urine output, blood pressure, uric acid, urine osmolality, blood biochemistry, and urinary cystatin C levels were assessed. Based on defined inclusion and exclusion criteria, 28 patients, 14 in each group, were recruited. The groups were similar in demographic and baseline laboratory characteristics. A significant decrease in body weight was observed in the intervention group (P = 0.002). The change in other measured parameters, including urine output and urinary cystatin C levels, was not reached statistical significance. Our findings suggest that the administration of HSS as an adjunct to loop diuretics could provide a safe and effective treatment for increasing urine output and decreasing weight in patients with heart failure.