Oral Diuretics Research Articles

741 A complex clinical mosaic of severe autoimmune calcific constrictive pericarditis with striking haemodynamic response to immunosuppressive therapy

Abstract Autoimmune constrictive pericarditis constitutes a conundrum to modern cardiology with much uncertainty surrounding both pathophysiology and optimal treatment strategies. We hereby describe the case of a 35-year-old woman of Nigerian origin with severe right heart failure secondary to calcific constrictive pericarditis. Her past medical history included coagulation factor XI deficiency, leukopenia, 2nd trimester miscarriage and premature labour due to placenta previa with fibrin deposition. Further investigations revealed atrial fibrillation, severe biatrial enlargement, moderate tricuspid and mitral regurgitation, pericardial thickening, post-capillary pulmonary hypertension and right ventricular dip-and-plateau pattern, compatible with severe constrictive pericarditis. Extensive screening for infectious and autoimmune causes only revealed borderline positive ANA (1:80). Thereafter, the patient underwent complete surgical pericardiectomy with pericardial biopsies revealing fibrous thickening, diffuse calcification and lymphocyte/macrophage infiltrates, in the absence of giant multinucleated cells or granulomas. The patient was later discharged but soon experienced relapse of exertional dyspnoea presenting with right-sided haemo-pneumothorax (requiring pleural drainage), diffuse alveolar haemorrhage, large right-sided basal and infrascissural pleural effusion, and ascites. She was treated with high dose iv furosemide, oral ibuprofen and colchicine, suspension of rate control medications, achieving initial reduction in pulmonary oedema and ascites, relapsing however after attempts to switch to oral diuretic therapy. Due to the finding of persistent lymphopenia, further immunological tests were conducted, revealing raised IgG1 levels as well as altered peripheral lymphocyte populations (raised CD4+/CD8+ ratio and CD8+ central memory, reduced CD8 effector memory). This finding in conjunction with the history of factor XI deficiency, 2nd trimester miscarriage and placental fibrin deposition as well as the observation of painful cutaneous nodules at sites of venepuncture, suggestive of Koebner’s phenomenon, veered the diagnostic focus to a potential autoimmune aetiology and in particular to systemic lupus erythematosus (>10 ACR-EULAR score points with case reports describing all the above as potential disease manifestations). Furthermore, revision of thoracic CT scans, demonstrated bilateral migratory peribronchovascular nodules with ground-glass halo. CT- guided biopsies thereof were performed revealing focal alveolar damage with capillaritis and alveolar haemorrhage, further corroborating the clinical suspicion of autoimmune disease and justifying the introduction of high-dose oral corticosteroid therapy. In liaison with our tertiary rheumatology centre, the patient was later switched to mycophenolate with gradual weaning from corticosteroid. Concurrent cardiological follow-up revealed persistence of good haemodynamic status (NYHA class II, absence of pulmonary oedema and ascites) with oral diuretic therapy, regression of cutaneous symptoms and echocardiography demonstrating consistent reduction in both mitral and tricuspid regurgitation. This constitutes to our knowledge the first report of autoimmune calcific constrictive pericarditis with significant haemodynamic response to immunosuppressive therapy. Despite the relative rarity of this disease entity, early recognition and instatement of immunosuppressive treatment may prove fundamental to halt and potentially reverse the haemodynamic progression of this highly morbid condition.

Diuretic Changes, Health Care Resource Utilization, and Clinical Outcomes for Heart Failure With Reduced Ejection Fraction: From the Change the Management of Patients With Heart Failure Registry.

Diuretics are a mainstay therapy for the symptomatic treatment of heart failure. However, in contemporary US outpatient practice, the degree to which diuretic dosing changes over time and the associations with clinical outcomes and health care resource utilization are unknown. Among 3426 US outpatients with chronic heart failure with reduced ejection fraction in the Change the Management of Patients with Heart Failure registry with complete medication data and who were prescribed a loop diuretic, diuretic dose increase was defined as: (1) change to a total daily dose higher than their previous total daily dose, (2) addition of metolazone to the regimen, (3) change from furosemide to either bumetanide or torsemide, and the change persists for at least 7 days. Adjusted hazard ratios or rate ratios along with 95% CIs were reported for clinical outcomes among patients with an increase in oral diuretic dose versus no increase in diuretic dose. Overall, 796 (23%) had a diuretic dose increase (18 episodes per 100 patient-years). The proportion of patients with dyspnea at rest (38% versus 26%), dyspnea at exertion (79% versus 67%), orthopnea (32% versus 21%), edema (60% versus 43%), and weight gain (40% versus 23%) were significantly (all P <0.001) higher in the diuretic increase group. Baseline angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (hazard ratio, 0.75 [95% CI, 0.65-0.87]) use were associated with lower likelihood of diuretic increase over time. Patients with a diuretic dose increase had a significantly higher number of heart failure hospitalizations (rate ratio, 2.53 [95% CI, 2.10-3.05]), emergency department visits (rate ratio, 1.84 [95% CI, 1.56-2.17]), and home health visits (rate ratio, 1.88 [95% CI, 1.39-2.54]), but not all-cause mortality (hazard ratio, 1.10 [95% CI, 0.89-1.36]). Similarly, greater furosemide dose equivalent increases were associated with greater resource utilization but not with mortality, compared with smaller increases. In this contemporary US registry, 1 in 4 patients with heart failure with reduced ejection fraction had outpatient escalation of diuretic therapy over longitudinal follow-up, and these patients were more likely to have sign/symptoms of congestion. Outpatient diuretic dose escalation of any magnitude was associated with heart failure hospitalizations and resource utilization, but not all-cause mortality.

Examination of the acute efficacy and safety about aggressive use of tolvaptan for early rising after admission in super-elder patients with congestive heart failure

Abstract Background From August 2015, for shortening of hospitalization period through efficient medical care in acute phase, we had introduced a unique clinical pathway (PATH) for congestive heart failure (CHF) cases. In PATH, since immediate taking of Tolvaptan, which is an strong oral diuretic and approver for use in the treatment of CHF cases since 2010 in Japan, after admission is specified, early diuresis makes it possible to achieve early rising from bed and streamline each medical care such as oxygen inhalation, continuous infusion, and urethral catheterization. Early rising from bed is particularly important for super-elder CHF patients who merge often frail. On the other hand, for super-elder CHF patients, it is feared that aggressive use of Tolvaptan may frequently cause dehydration, renal damage caused by it, or hypernatremia, which is a peculiar side effect about the drug. Purpose In this study, we examined the usefulness and safety of active use of Tolvaptan by introducing PATH in patients with super-elder CHF patients. Methods We set up three groups, NE group consist of 37 CHF cases (90 years old or over) who admitted in our hospital before (without) introduction of PATH between April 2014 and July 2015, PE group consist of 130 CHF cases (90 years old or over) and PY group consist of 466 CHF cases (under 90 years old) who ware admitted with introduction of PATH between August 2015 and July 2020. And in each group, we investigated various medical conditions in their acute phase after admission and the incidence of adverse events related to oral administration of tolvaptan, and examined the differences between three groups. Results Between NE group and PE group, there were no significant differences in mean age, pre-hospital living status, or clinical status at admission (Figure 1). But due to lean and efficient CHF care, the average length of hospitalization period was significantly shorter in PE group. And, in PE group, each medical care was performed as efficiently as in PY group, but the progression of renal damage or hypernatremia that required unscheduled discontinuation of tolvaptan use occurred more frequently in PE group (Figure 2). Conclusions Aggressive Tolvaptan use through our unique clinical pathway for congestive heart failure cases seemed to be useful even in super-elder patients. Although we thought that the safety of active use of tolvaptan for super-elder patients was well tolerated considering the results of this study, the incidence of adverse events such as hypernatremia was clearly higher in super-elder patients than in non-super-elder patients. It seemed that we should pay close attention to the clinical data of super-elder patients after introduction of tolvaptan. Funding Acknowledgement Type of funding sources: None. Figure 1Figure 2

Profile and early outcomes of surgical reconstruction of coronary artery atresia in children.

Coronary artery atresia is a rare coronary artery anomaly in children and has a high rate of misdiagnosis. We aimed to summarize the profile and early outcomes after the surgical reconstruction of coronary artery atresia in children. A retrospective analysis was performed in 12 consecutive patients with coronary artery atresia who were admitted to the Department of Paediatric Cardiac Surgery of Fuwai Hospital between October 2016 and September 2020. Ten patients underwent surgical reconstruction of the coronary artery with the pulmonary artery anterior wall, and 8 patients underwent concomitant mitral valvuloplasty. There were 6 females and 6 males, with an age of 1.75 years [interquartile range (IQR), 1.0-3.5] and weight of 10.0 kg (IQR, 8.9-14.75). There were 10 cases of left coronary artery atresia and 2 cases of right coronary artery atresia. All the patients were initially misdiagnosed in the outpatient clinic, but further nonselective coronary angiography confirmed the diagnosis of coronary artery atresia. In all 10 patients with mitral regurgitation, echocardiogram of the mitral valve chordae and papillary muscle revealed ischaemic changes. The clamp time was 89.0 min (IQR, 75.0-101.0), the pump time was 126.0 min (IQR, 119.0-132.0) and the intensive care unit stay time was 1.5 days (IQR, 1.0-3.0). No perioperative deaths were noted. After 9.5 months (IQR, 5.5-13.5) of follow-up, 2 patients with fractional shortening that significantly decreased to 14.1% and 14.8% died and 1 patient had moderate pericardial effusion that improved after treatment with oral diuretics. Coronary artery ultrasound and enhanced computed tomography showed a patent main coronary artery in all the patients. Coronary artery atresia in children is often associated with mitral regurgitation, and mitral valve chordae and papillary muscle exhibit ischaemic changes. Coronary artery reconstruction is safe and effective in children with coronary artery atresia.

Association between intestinal oedema and oral loop diuretic resistance in hospitalized patients with acute heart failure.

AimsIntestinal oedema is one of the manifestations associated with right‐sided heart failure (HF), which is known to be associated with poorer patient outcomes. We attempted to reveal the association between intestinal oedema and diuretic resistance in hospitalized patients with acute HF.Methods and resultsAmong 213 hospitalized patients with acute HF, abdominal ultrasonography was performed under clinically stable conditions after initial HF treatments. The association among abdominal ultrasonographic parameters, maintenance doses of loop diuretics, and responsiveness to initial loop diuretic treatment was evaluated. Higher mean colon wall thickness (CWT) independently correlated with a higher dose of loop diuretics at enrolment (adjusted β = 0.198, P = 0.0004). Increased mean CWT also correlated with poor response to oral loop diuretics as an initial treatment, whereas it did not correlate with the response to intravenous loop diuretics. Discrimination of non‐responders to initial oral loop diuretics resulted in a sensitivity of 0.772 and a specificity of 0.733 using a mean CWT cut‐off value of ≥3 mm.ConclusionsIn hospitalized patients with acute HF, a strong correlation was identified among the severity of intestinal oedema, required quantities as maintenance loop diuretic doses, and poor responsiveness to oral loop diuretics at admission.

Trial of Oral Diuretics Prior to Discharge Is Not Associated With Improved Outcomes in Decompensated Heart Failure.

BackgroundCurrent heart failure guidelines recommend transition of intravenous (IV) diuretics to oral > 24 h prior to hospital discharge. The aim of this study was to determine whether transition to oral diuretics prior to discharge in patients hospitalized with decompensated systolic heart failure (SHF) was associated with improved 30-day events.MethodsThis was a retrospective cohort study, in which adults admitted to the Loma Linda Medical Center for 3 - 14 days with a primary discharge diagnosis of acute on chronic SHF were included. Mortality data were obtained from the National Death Index, while readmission only to our facility was included. The t-test and Chi-square test were used for analyses.ResultsA total of 314 patients were studied. Patients who were managed with guideline-recommended trial of oral diuretics, and patients who continued to receive IV diuretics on the last full hospital day were overall similar in baseline characteristics. Patients who received oral diuretics on the day prior to discharge had longer length of stay, less weight loss, were discharged on lower diuretic doses (all P < 0.05), and had similar outcomes of 30-day readmission and 30-day hospitalization-free survival.ConclusionsThe transition to oral diuretics prior to discharge in patients with decompensated SHF was not associated with improved 30-day outcomes. These results require validation in prospective trials but suggest that guideline recommendations regarding transitioning to oral diuretics prior to discharge may deserve re-evaluation.

MO317DETERMINANTS OF LENGHT OF HOSPITAL STAY (LOS) IN NEPHROTIC SYNDROME PATIENTS

Abstract Background and Aims Generalized edema, non responsive to oral diuretics, is one of the main causes of hospital admission for nephrotic syndrome patients. Although hospital length of stay (LOS) may vary widely, in 2017 the average LOS in acute-care hospitals was lower than 8 days in OECD countries. The aim of the present study was to determine the factors commonly associated with a longer LOS in patients admitted for edema due to nephrotic syndrome in the Nephrology Unit of ICS Maugeri, Pavia, Italy Method In this retrospective study we reviewed the medical records of all patients admitted for nephrotic syndrome between 2012-2020 in the Nephrology Unit of ICS Maugeri. Inclusion criteria were the following: age between 18-85 years of age; severe edema non responsive to oral, low dose diuretics; patients with heart failure, serum creatinine &amp;gt; 3.5 g/dl or on dialysis treatment were excluded from the study. Patients were divided into two groups according to the length of stay: ≤ 7 days or ≥ 8 days. Age, gender, serum protein concentration, creatinine, and hemoglobin; serum cholesterol and tryglicerides, urinary protein excretion rate; types of glomerular disease, weight loss were recorded. Student T tests and one-way Anova were performed to evaluate the differences between the means. Results 60 patients (42 male, 18 female) with a total number of hospital accesses of 93 were enrolled in the study. Mean age was 66.8 ± 13.07 years. Average LOS was 9.02 ± 7.4 days. Protein excretion rate was 6.7 ± 3.6 g/24 hours at the admission and was not statistically changed at discharge. Mean total serum protein and creatinine concentration at the admission were 4.7 ± 0.8 g/dl and 1.8 ± 1.1 mg/dl respectively. Patients with LOS &amp;lt; 7 days were younger (64 ± 11.9 vs 69 ± 13.6 years, p &amp;lt;0.05), had a lower serum creatinine (1.55 ± 0.92 vs 2.08 ± 1.2 mg/dl, p&amp;gt;0.001) and a significantly higher total serum protein concentration (5.02 ± 0.77 vs 4.65 ± 0.76 g/dl, p&amp;lt; 0.001) and haemoglobin (12.6 ± 1.8 vs 11.4 ± 1.8 g/dl, p&amp;lt; 0.05) compared to patients with longer LOS. Proteinuria was not significantly different between the two groups (6.27 ± 3.36 vs 7.1 ± 3.9 g/24 hours, p= NS). While serum cholesterol and tryglicerides were higher in the group of patients with longer LOS, weight loss was similar in the two groups at discharge. Although the difference was not significant, the group with longer hospitalization had a greater number of patients with a diagnosis of focal segmental glomerulosclerosis (FSGS) Conclusion Our results demonstrate that age, total serum protein concentration, serum creatinine, higher lipids and probably the diagnosis of FSGS may affect the hospital length of stay of patients with nephrotic syndrome admitted for severe edema. A more aggressive diuretic treatment may be needed in elderly nephrotic syndrome patients with lower GFR and total serum protein concentration.

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'?

Outpatient Intravenous Diuretic Clinic: An Effective Strategy for Management of Volume Overload and Reducing Immediate Hospital Admissions.

BackgroundHeart failure (HF) readmissions pose a major burden to patients and the healthcare system. We evaluated whether outpatient intravenous (IV) diuretic clinic is a safe and effective strategy to reduce HF hospitalizations.MethodsWe reviewed 34 clinic encounters with 27 unique patients (median age 72) who had volume overload refractory to oral diuretics that were treated with IV furosemide in the outpatient clinic. One patient (2.9%) was admitted to the hospital directly, and the rest were discharged home.ResultsMore than 80% of the patients had continued weight loss for 7 days (median weight loss 5.4 lb). During the median follow-up period of 15 months, 15 patients (56%) had subsequent HF hospitalizations. HF admission was delayed by a median of 22 days from the clinic visit and 138 days from the previous HF admission prior to clinic visit. Estimated cost saving per admission avoided was $10,395. One patient developed severe hypokalemia (< 3.0 mmol/L), and the remaining had no adverse events.ConclusionOutpatient IV diuresis is effective and well tolerated. It leads to significant weight loss, persisting in the majority of patients for 7 days. In select patients, it should be considered as a strategy to rapidly improve symptoms, reduce hospitalizations and decrease costs.

Diuretics increase Blood Creatinine in the Treatment of Hypertension

Background: Diuretics have been used in the treatment of hypertension by either alone or combining itwith other antihypertensive drugs. It treated about 50% of hypertensive patients alone and about 80% whentreatment was a combination with other antihypertensive drugs. Oral diuretics are used as an initiatingantihypertensive treatment in stepped care approach the antihypertensive management .One such loop diureticcalled as Furosemide is being regularly used in different stages of acute kidney injury and hypertension.Lowering the blood pressure is ultimately reducing the risk of cardiovascular morbidity and mortality. Thesideeffects of diuretics are dose dependent. The intake of Furosemide will bring an increase in the creatininelevel.It must be noted that if the diuretics are been taken for prolong usage, it might over-stress the functionof kidney which will result in sodium resorption increase and elevation of creatinine levels.Material and Method: Twenty hypertensive patients in the age range of 40 to 76 years old were subjectedto a treatment with furosemide(20mg/day) for a variable period of one to three years. The analysis of bloodsamples was being done against the serum creatinine following the colorimetric method. The results werestatistically processed and analyzed by SPSS using the T-test method.Results: The trial was runon the participants being either hypertensive patients or normal individuals. TheMean (+/-SD) of age was 59.4 +/- 10.3, mean (+/-SD) of duration of treatment with furosemide was 2.1 +/-0.7. Mean (+/-SD) of serum creatinine in the control individual was 0.9 +/- 0.22, and mean serum creatininein hypertensive patients treated with furosemide was 2.37 +/- 0.69. (P value &lt; 0.05.)Conclusion: The diuretic Furosemide can increase thelevel of creatinine.Aim of the work: Determine the effect of diuretics (furosemide) on serum creatinine.

Immediate Treatment of Sudden Sensorineural Hearing Loss: A Case Study

Immediate Treatment of Sudden Sensorineural Hearing Loss: A Case Study

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

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

Temporal trends of a vasopressin V2 receptor antagonist in heart failure using a nationwide database in Japan.

AimsReal‐world data on the use of tolvaptan, an oral selective vasopressin 2 receptor antagonist, for patients with heart failure (HF) are not available in Western countries because tolvaptan is not indicated in the Western countries for volume overload in HF. This study aimed to investigate the current status and recent trends of tolvaptan use for HF in Japan by analysing a nationwide Japanese Diagnosis Procedure Combination database.Methods and resultsWe retrospectively identified 257 812 patients hospitalized because of HF between 1 April 2008 and 30 November 2018. The diagnosis of HF at admission was based on the International Classification of Diseases, Tenth Revision, and in‐hospital treatment. We investigated patient characteristics, in‐hospital diuretic treatment, and tolvaptan treatment after discharge. The proportion of patients who were prescribed with tolvaptan for HF increased from 3.2% in 2011 to 39% in 2018. Since 2015, tolvaptan was prescribed within 2 days of hospitalization in >50% of HF cases. At discharge of a patient who was prescribed with tolvaptan, the rate of oral loop diuretic prescription at a dose ≥80 mg decreased, while the rate of diuretic prescription at a dose <40 mg increased. After discharge, the rate of tolvaptan prescription gradually increased from 34.0% in 2011 to 69.7% in 2018; however, tolvaptan prescriptions lasting >14 days decreased after 2012.ConclusionsThis large‐scale survey indicated an increased rate of tolvaptan prescription and an early shift to tolvaptan treatment in patients with HF in Japan. The prognostic effects of this change in HF treatment remain unclear.

Urinary chlorine: a potential biomarker of diuretic resistant patients

Abstract Background Natriuresis is gaining growing interest in identifying diuretic resistance (DR) patients. However, it has not been proved useful beyond the first day with intravenous (iv) furosemide. Moreover, data regarding urinary chlorine (uCl) or urinary potassium (uK) are scarce. We sought to assess the urine electrolyte pattern in acute heart failure (AHF) outpatients to identify those who will present DR. Methods Single-center prospective registry of outpatients with AHF who need iv furosemide. In visit 1 (V1), baseline spot urine sample was collected. Furosemide iv bolus plus intensification of oral diuretics were performed. In control visit (V2), baseline spot urine sample was collected and congestion data were evaluated. Urine electrolytes were assessed in relation to DR (defined as need of iv furosemide in V2 due to persistent congestion). Results From June to December 2019, 76 patients were included: median age of 75.5 years (68.2–82), glomerular filtration 40 ml/min/1.73m2 (29.2–59.2) and NT-proBNP 3340 ng/L (1296–7044). In V1, DR patients showed higher levels of uK and lower uNa/uK than NDR (p=0.014 and p=0.007, respectively). In V2, after a median of 6 (6–15) days of intensified diuretic treatment, uNa and uCl dropped with adequate decongestion but not in DR patients (p=0.020 and p=0.001, respectively). Thus, DR patients showed in V2 higher uCl and similar uNa than NDR (table). Conclusions After several days of intensified diuretic treatment, uCl and uNa dropped during proper decongestion but not in DR patients, showing higher levels of uCl than NDR. Mantained levels of uCl could help to identify patients with persistent congestion. Funding Acknowledgement Type of funding source: None

A RandomisEd ControLled TrIal of ChEwing Gum to RelieVE Thirst in Chronic Heart Failure (RELIEVE-CHF)

Thirst is a common and troublesome symptom of patients with chronic heart failure (CHF). To date, there are no interventions to help alleviate thirst in this cohort. Chewing gum is a novel intervention, which has been tested in people undergoing haemodialysis, also prescribed with a fluid restricted therapy. The aim of this study was to determine the effect of chewing gum on the level of thirst in the short-term (average of 24 hours each day for 4 days) and in the longer-term (Days 7, 14 and 28) individuals with CHF. Seventy-one (71) individuals with CHF on oral loop diuretics were randomised to chewing gum (n=36) or control (n=35) for 2 weeks. Both groups were assessed for their level of thirst at Days 1-4, 7, 14 and28. Significant improvements in the level of thirst of those who received chewing gum compared to the control group at Day 4 (p=0.04) and Day 14 (p=0.02) were observed. Chewing gum provided relief from thirst in the short-term and in the longer term. This trial provides important information to inform future clinical trials on ways to relieve thirst.

Frequency of Transition to Oral Loop Diuretics Prior to Discharge

Introduction Heart failure guidelines recommend that patients with acute decompensated heart failure (ADHF) be transitioned to oral (PO) loop diuretics prior to discharge but little evidence supports this recommendation. Objectives We sought to identify the frequency that patients admitted for ADHF are transitioned to PO loop diuretics prior to discharge, identify predictors for transitioning to PO loop diuretics, and compare outcomes between patients converted to PO loop diuretics (PO group) to those who were not (IV group). Methods We conducted a retrospective chart review of unique adult patients hospitalized for ADHF at our facility between 9/1/2017 and 8/31/2019. Patients hospitalized for ADHF (ICD-10 I50.xx) with evidence of fluid overload, treated with IV loop diuretics during the first 24 hours of admission, and discharged home with a prescription for PO loop diuretic were included. Patients were excluded if they were on dialysis, left against medical advice, received palliative care referral while inpatient, or had a history of cirrhosis or received > 50mg of aldosterone antagonist a day. Patient demographics, clinical features, and practice patterns were characterized to identify predictors of PO transition. Thirty-day readmission rates were compared between the PO and IV groups. Results Among 240 patients included, 155 (65%) patients were transitioned to PO loop diuretics prior to discharge (PO group). Mean age was 63 years, most were men (55%) of African American (66%) descent. Compared to the IV group, the PO group had higher baseline potassium (4.3 vs 4.1 mEq/L, p=0.010), lower eGFR (52 vs 60 mL/min/1.73m2, p=0.016), were less likely to be on hydralazine (12.9% vs 24.7%, p=0.020), and more likely to be on a thiazide-type diuretic (9.7% vs 2.4%, p=0.034) on admission. Neither age, gender, blood pressure, renal function, nor electrolytes were significant predictors of transitioning to PO loop diuretics prior to hospital discharge. Within 30 days, 36 (23.2%) patients in the PO group were rehospitalized compared to 19 (22.4%) patients in the IV group (p=0.88). Conclusions Most patients admitted for ADHF were transitioned to PO loop diuretics prior to discharge. Although differences were noted in baseline characteristics, we did not identify any significant predictors for patients transitioned to PO diuretics. Thirty-day readmission rates were similar between patients who were and were not transitioned. Further study is warranted to identify the best approach for transitioning ADHF patients to PO diuretics prior to discharge.

Initial Experience of A Heart Failure Disease Management Clinic During the Covid-19 Era

BackgroundThe COVID-19 pandemic has necessitated significant alterations in ambulatory heart failure (HF) care, primarily with the introduction of telemedicine. We describe our initial experience caring for patients in the COVID-19 era in the Johns Hopkins Heart Failure Bridge Clinic (JHHFBC), an ambulatory disease management and diuresis clinic aimed at preventing hospitalizations.MethodsThe JHHFBC sees about 2500 patients per year with 25% of those patients needing intravenous diuretics in the clinic. Starting March 16, 2020, we implemented a COVID-specific workflow incorporating telemedicine, which the clinic had previously not been utilizing. Patient visit outcomes were adjudicated, including change in diuretic dosing, intravenous diuretic administration, and need for hospitalization.ResultsFrom March 16, 2020 to April 24, 2020 we had 116 patients seen 164 times (Figure 1). The average age of patients was 61 ± 14 years, 50% female, and 70% Black. Average left ventricular ejection fraction was 25 ± 21% with 45% nonischemic cardiomyopathy, 14% ischemic cardiomyopathy, 6% amyloid, 35% had heart failure with preserved ejection fraction. The majority of patients were New York Heart Association (NYHA) class II or III (109, 94%). Reasons for clinic referral included an equal frequency of post hospital discharge, worsening HF symptoms and routine follow up. Of the 96 telemedicine visits, 23% resulted in oral diuretic dose adjustment and 6 patients were referred for in-person visits. Of the 68 in-person visits, 34 (50%) resulted in intravenous diuretic administration in clinic, with 8 referrals to the emergency department or for direct admission. There were 2 referrals for cardioversion and 3 referrals to hospice by the clinic. Two of 16 clinic patients that were tested for Covid 19 were positive.ConclusionWe found that HF patients could be effectively managed via telemedicine, however a subset still benefit from in-person assessment and access to ambulatory intravenous diuresis to avoid hospitalization. We hope these initial experiences will lend insights to optimization of future outpatient HF care, including the use of telemedicine, even after the current global health emergency.

Management of Heart Failure In Cardiac Amyloidosis Using An Ambulatory Diuresis Clinic: An Analysis of Safety And Health Care Utilization

Background Restrictive cardiomyopathy in cardiac amyloidosis (CA) mainly occurs due to light chain (AL) or transthyretin (ATTR) protein deposition in the myocardium. Recurrent congestion related to HF can be challenging to manage in CA, often requiring high dose diuretics and frequent hospitalizations. Though therapies are available for CA that may prolong survival, these do not reverse the cardiomyopathy that may be present at time of diagnosis. Innovative outpatient strategies are needed to effectively manage HF in patients with CA. Methods The Johns Hopkins Heart Failure Bridge Clinic is an outpatient HF disease management clinic with the ability to administer intravenous (IV) diuretics. We retrospectively studied patients with CA seen in the clinic in 2017 for 1) safety outcomes of IV diuresis visits and 2) health care utilization at 30, 90, and 180 days pre- vs. post-index clinic visit. Results Forty-four patients with CA (mean age 71.3±9.7 yrs, 17 AL, 27 ATTR; 75% male, 48% AA) had 203 clinic visits (56 for IV diuresis) over 6 months. Oral diuretic dosage was decreased at 29 (14%) visits and increased at 67 (33%) visits. There was no severe acute kidney injury or symptomatic hypotension with IV diuresis. Eight (14%) IV diuretic visits resulted in asymptomatic hypotension, with 4 events in 1 AL patient (Table 1). There was a large decrease in ED and inpatient visits and associated charges when comparing pre- to post-index visit time periods (Figure 1). The proportion of days hospitalized/1000 patient days of follow-up decreased as early as 30 days (147.3 vs 18.1/1000 patient days of follow-up, p<0.001) and persisted through 180 days (33.6 vs 22.9/1000 patient days of follow-up, p<0.001) pre- vs. post-index clinic visit (Figure 1). Conclusion This is the first description of the use of an outpatient diuresis clinic to manage HF in cardiac amyloidosis. Outpatient IV diuretic administration is safe and HF management in this setting reduces acute care utilization in a patient population that contributes to a high health care burden. Restrictive cardiomyopathy in cardiac amyloidosis (CA) mainly occurs due to light chain (AL) or transthyretin (ATTR) protein deposition in the myocardium. Recurrent congestion related to HF can be challenging to manage in CA, often requiring high dose diuretics and frequent hospitalizations. Though therapies are available for CA that may prolong survival, these do not reverse the cardiomyopathy that may be present at time of diagnosis. Innovative outpatient strategies are needed to effectively manage HF in patients with CA. The Johns Hopkins Heart Failure Bridge Clinic is an outpatient HF disease management clinic with the ability to administer intravenous (IV) diuretics. We retrospectively studied patients with CA seen in the clinic in 2017 for 1) safety outcomes of IV diuresis visits and 2) health care utilization at 30, 90, and 180 days pre- vs. post-index clinic visit. Forty-four patients with CA (mean age 71.3±9.7 yrs, 17 AL, 27 ATTR; 75% male, 48% AA) had 203 clinic visits (56 for IV diuresis) over 6 months. Oral diuretic dosage was decreased at 29 (14%) visits and increased at 67 (33%) visits. There was no severe acute kidney injury or symptomatic hypotension with IV diuresis. Eight (14%) IV diuretic visits resulted in asymptomatic hypotension, with 4 events in 1 AL patient (Table 1). There was a large decrease in ED and inpatient visits and associated charges when comparing pre- to post-index visit time periods (Figure 1). The proportion of days hospitalized/1000 patient days of follow-up decreased as early as 30 days (147.3 vs 18.1/1000 patient days of follow-up, p<0.001) and persisted through 180 days (33.6 vs 22.9/1000 patient days of follow-up, p<0.001) pre- vs. post-index clinic visit (Figure 1). This is the first description of the use of an outpatient diuresis clinic to manage HF in cardiac amyloidosis. Outpatient IV diuretic administration is safe and HF management in this setting reduces acute care utilization in a patient population that contributes to a high health care burden.

Impact of acute kidney injury on prognosis and the effect of tolvaptan in patients with hepatic ascites

In hepatic cirrhosis, ascites and acute kidney injury (AKI) portend poor prognosis. We examined the incidence and characteristics of AKI in patients with hepatic ascites and the impact of diuretics on AKI onset. This study included 337 patients with hepatic ascites treated with oral diuretics during September 2013-June 2019. Incidence of AKI, cumulative survival by AKI status, and prognostic factors were investigated. Patients were divided into those treated with tolvaptan (TLV) [TLV group (n = 244)] and those not treated with TLV [control group (n = 93)]. After propensity score matching, the incidence of AKI and changes in renal function and doses of diuretics were compared. The incidence of AKI overall was 35% (n = 118). Patients with AKI had a significantly worse survival than those without AKI (P = 0.001), indicating that AKI is an independent prognostic factor for hepatic ascites (P = 0.025). After adjustment for background factors in the two groups (n = 77 each), the TLV group had a significantly lower incidence of AKI (27.6% vs. 44.7%, P = 0.028). While renal function worsened with higher natriuretic agent doses in the control group, no significant change was observed in the TLV group, suggesting that TLV is an independent prognostic factor for AKI onset. Our study suggests that concomitant AKI significantly worsens survival in Japanese patients with hepatic ascites, and TLV and natriuretic agent combination therapy might lead to an excellent synergistic therapeutic effect of hepatic ascites and inhibition of AKI onset.

Toxicity assessment of sub-acute and sub-chronic oral administration and diuretic potential of aqueous extract of Hibiscus sabdariffa calyces

BackgroundFood and herbal usage of Hibiscus sabdariffa (HS) is attaining improved global relevance and acceptance without recourse to its potential toxic effects. This study investigated the safety profile of acute, sub-acute, sub-chronic administrations and diuretic potential of aqueous extract of Hibiscus sabdariffa calyces (AEHSC). MethodAcute oral toxicity, sub-acute and sub-chronic toxicity as well as diuretic studies were carried out on HS. A total of 20 Wistar rats were used for each toxicity study and assigned into four groups of five rats. The extract was administered as a single daily dose of 125, 250 and 500 mg/kg body weight (bwt) for 28 and 90 days respectively. To evaluate diuretic activity, 25 rats were divided into five groups of five rats and administered normal saline, hydrochlorothiazide 10 mg/kg, AEHSC 67.5, 125 and 250 mg/kg via the oral route. Urine sample was collected after 18 h, volume measured and concentration of electrolytes analyzed. The hematological and biochemical parameters were evaluated as well as the histopathology of kidney and liver. ResultsThe acute oral toxicity was found to be >2000 mg/kg. AEHSC did not alter concentration of WBC, MCV, MCHC, lymphocyte as well as total and direct bilirubin in the sub-acute study. However, AEHSC significantly (p < 0.05) increased total protein, albumin, globulin, Na+, Cl−, HCO3- and platelet levels, while levels of uric acid, creatinine, K+, RBC, Hb, total cholesterol, triglycerides, LDL-C, HDL-C and atherogenic index were decreased significantly (p < 0.05). In the sub-chronic study, AEHSC significantly (p < 0.05) increased the levels of globulin, urea, creatinine, MCH and atherogenic index. The concentrations of uric acid, WBC, platelets and HDL-C were significantly (p < 0.05) decreased. In both the sub-acute and sub-chronic studies, activities of ALP, ALT, AST, GGT and LDH in selected organs were altered without significant increase (P < 0.05) in activity of these enzymes in the serum. The AEHSC at all the doses showed remarkable diuretic activity during 18 h period comparable to hydrochlorothiazide. The extract also showed a non-dose-dependent increase in excretion of electrolytes. Histological analysis of sections of the liver and kidney for both sub-acute and sub-chronic studies showed normal histology comparable to the control group. ConclusionThis study revealed AEHSC has some toxic effects in rats on sub-chronic administration. In addition, the extracts produced a significant diuretic activity. Hence, prolonged oral consumption of the extract may not be recommended.