Signs Of Volume Overload Research Articles

Impact of protocolized diuresis for de-resuscitation in the intensive care unit

ObjectiveAdministration of diuretics has been shown to assist fluid management and improve clinical outcomes in the critically ill post-shock resolution. Current guidelines have not yet included standardization or guidance for diuretic-based de-resuscitation in critically ill patients. This study aimed to evaluate the impact of a multi-disciplinary protocol for diuresis-guided de-resuscitation in the critically ill.MethodsThis was a pre-post single-center pilot study within the medical intensive care unit (ICU) of a large academic medical center. Adult patients admitted to the Medical ICU receiving mechanical ventilation with either (1) clinical signs of volume overload via chest radiography or physical exam or (2) any cumulative fluid balance ≥ 0 mL since hospital admission were eligible for inclusion. Patients received diuresis per clinician discretion for a 2-year period (historical control) followed by a diuresis protocol for 1 year (intervention). Patients within the intervention group were matched in a 1:3 ratio with those from the historical cohort who met the study inclusion and exclusion criteria.ResultsA total of 364 patients were included, 91 in the protocol group and 273 receiving standard care. Protocolized diuresis was associated with a significant decrease in 72-h post-shock cumulative fluid balance [median, IQR − 2257 (− 5676–920) mL vs 265 (− 2283–3025) mL; p < 0.0001]. In-hospital mortality in the intervention group was lower compared to the historical group (5.5% vs 16.1%; p = 0.008) and higher ICU-free days (p = 0.03). However, no statistically significant difference was found in ventilator-free days, and increased rates of hypernatremia and hypokalemia were demonstrated.ConclusionsThis study showed that a protocol for diuresis for de-resuscitation can significantly improve 72-h post-shock fluid balance with potential benefit on clinical outcomes.

26-Year-Old Woman With Shortness of Breath and Chest Pain

26-Year-Old Woman With Shortness of Breath and Chest Pain

P700 TEE guidance of percutaneous closure the inlet and exit of ascending aorta pseudoaneurysm in a patient had triple valve replacement

Abstract Funding Acknowledgements none OnBehalf none Introduction Surgical treatment of ascending aortic pseudoaneurysms (AAPA) that develop following cardiac surgery carries significant morbidity and mortality. However, there are emerging reports of transcatheter closure of AAPA. To the best of our knowledge, this is the first reported case where the APA communicates with the left ventricle (LV) cavity with significant diastolic volume overload mimic severe aortic regurgitation. We added to the complications of APA, a fistulous communication with LV causing severe volume overload and heart failure. Case description: Thirty-two years old female underwent mechanical aortic and mitral valve replacement and bioprosthetic tricuspid valve replacement in April 2013. At October 2016, she started to have progressive shortness of breath. TEE revealed large ascending aorta pseudoaneurysm that communicates with LV cavity. Cardiac computed tomography (CT) with contrast revealed a sizeable noncoronary sinus of Valsalva pseudoaneurysm 47mm x 39mm. Surgical excision of the aneurysm decided, but the patient refused any surgical procedure. Percutaneous closure of the inlet and exit of the aneurysm discussed and accepted by the patient. The procedure of transcatheter aneurysm device closure performed successfully with TEE guidance (Figure). A: showed the aneurysm exit to the LV while D: showed its inlet from the aorta. The wire passed the aneurysm inlet at ascending aorta to its outlet in the LV (B). Six mm VSD device deployed closing the aneurysm exit to LV (C). Another 6mm VSD device deployed closing the aneurysm inlet (E). Transgastric long axis aorta view showed no more flow to LV. Midessophageal Short axis view showed no flow between ascending aorta and the aneurysm. Fluoroscopy injection inside the aneurysm (F), another two devices left inside the aneurysm (G). The patient was observed in the cardiac care unit (CCU) for two days, then discharged home in good condition. She was followed in the outpatient clinic after two weeks, and she is doing well with no more shortness of breath. Follow up echo after one year of the procedure showed a small remaining flow from the aneurysmal cavity to the left ventricle. (H and K) compares apical three-chamber view before and one year after closure. Discussion: Preprocedural CT and Intraprocedural TEE are mandatory in determining the size and location of AAPA. Also, the type and size of suitable devices for closure. Overall, the success rate for percutaneous closure is 80%, with a 12% device embolization rate and an 8% failure rate of the transcatheter technique to close the pseudoaneurysm, necessitating conversion to surgical closure. In most reported cases the AAPA had only communication with the aorta. In our case, the AAPA also communicates with the LV cavity that requires the closure of both communications. Conclusion: Percutaneous closure of the inlet and exit of AAPA with TEE guidance is feasible. Long term follow up is required in a large number of patients. Abstract P700 Figure: AAPA device closure

P879 3D transoesophageal echocardiography to asses a case of a non-ebstein tricuspid valve congenital regurgitation

Abstract Introduction Due to the complexity of congenital heart disease and limitations of transthorathic echocardiogram (TTE), especially in adult patients, it is not unusual to need other image techniques to assess cardiac anatomy and function. The most common primary anomaly of tricuspid valve (TV) is Ebstein anomaly, but there are other much rarer primary anomalies of this valve consisting in prolapse, cord retraction.... without downward displacement of the leaflet, generally causing tricuspid regurgitation (TR) that can be severe and sometimes intervention is needed, preferably reparation. Due to anatomical issues, it is difficult to assess anatomy of TV in TTE, so sometimes 3D-TTE must be performed to clarify the mechanism and to measure orifice, but when transthoracic view is not enough, 3D transoesophageal echocardiogram (TOE) can be useful for this purpose. Case We report the case of a 15-year-old boy that was referred to our clinic because of shortness of breath and a systolic tricuspid murmur. TTE was performed and an image compatible with tricuspid valve prolapse with no apical displacement of any leaflets (Figure, A) causing severe TR (Figure, B) was noticed, as well as severely dilated right chambers, with good ejection fraction of both ventricles. It was not clear the mechanism so 2D TOE was done, showing a prolapse of a leaflet (Figure, C) causing severe TR (Figure, D). The mechanism was finally clarified by 3D TOE (figure E). This was a prolapse of lateral portion of posterior leaflet (asterisk) with restrictive movement of anterior (triangle) and septal (arrow) ones, causing a huge coaptation defect in systole leading to a very severe tricuspid insufficiency with signs of volume overload of right ventricle. There was no atrial septal defect and pulmonary drainage anomalies were ruled out by cardiac magnetic resonance. Patient was referred to surgery due to symptoms and great dilatation of right chambers. Conclusión: Due to anatomical complexity and limitations of echography, cross and multimodality cardiac imaging is usually needed in assessing congenital heart disease. Apart from Ebstein anomaly, other congenital entities of tricuspid valve such as prolapse and/or retraction can lead to severe tricuspid regurgitation. Due to limitations of 2D TTE in assessing tricuspid valve anatomy, 3D TTE has to be performed, but if it is not enough, 3D TOE can be an option to evaluate mechanism and directly see the orifice of regurgitation in congenital disease of tricuspid valve. Abstract P879 Figure

Annals for Educators - 15 January 2019.

Annals for Educators - 15 January 2019.

Acetazolamide as Add-on Diuretic Therapy in Exacerbations of Chronic Heart Failure: a Pilot Study.

BackgroundCongestion is the main cause of morbidity in patients with heart failure. Treatment of fluid overload is often challenging in everyday clinical practice.ObjectiveThe aim of this study was to determine the diuretic effect of acetazolamide in patients with exacerbations of chronic heart failure, in addition to their stable diuretic therapy.MethodsThis was a single-center, unblinded study. Patients hospitalized with chronic heart failure exacerbations, with left ventricular ejection fraction (EF) < 50% and signs of volume overload, with a stable dose of diuretics anticipated by the attending physician over the next 4 days, were considered eligible for the study. On day 1, patients were randomized to receive acetazolamide orally, once daily (dose-adjusted to body weight) or no treatment (control group) as add-on diuretic therapy, on days 2 and 3. Diuresis, natriuresis, fluid balance, and symptoms were assessed daily, up to day 4.ResultsTwenty patients (mean ± standard deviation age 72 ± 11.6 years; 85% men; mean EF 33.8 ± 11.4%; mean N-terminal pro-B-type natriuretic peptide 8064 ± 5593 pg/mL; mean intravenous furosemide dose 105 ± 55 mg) were enrolled. Diuresis, natriuresis, fluid balance, and symptoms were stable on days 1–4 in the control group. An increase in diuresis and natriuresis, and a greater change in fluid balance after administration of acetazolamide, were observed in patients randomized to acetazolamide. On day 4, there was a significant difference in fluid balance between the acetazolamide and control groups (−666 ± 1194 mL vs. +332 ± 705 mL; p = 0.035), and dyspnea was lower in patients receiving acetazolamide (visual scale, p < 0.001; 5-point Likert scale, 1.444 vs. 2.222; p = 0.04)ConclusionsIn this pilot study, the addition of acetazolamide to the background diuretic regimen in patients with chronic heart failure exacerbations produced an additional diuretic effect and alleviation of dyspnea.

Heart Failure Is Common and Under-Recognized in Patients With Arrhythmogenic Right Ventricular Cardiomyopathy/Dysplasia.

Heart failure (HF) prevalence in arrhythmogenic right ventricular cardiomyopathy/dysplasia (ARVC/D) varies depending on study cohort and is not well characterized. This study sought to determine prevalence and predictors of HF in ARVC/D. Clinical HF, defined as at least 1 HF sign or symptom, was retrospectively adjudicated for 289 patients meeting ARVC/D Task Force Criteria. HF was present in 142 patients (49%): 113 had isolated RV involvement and 29 had evidence of LV dysfunction. Average age of HF onset was 40±14 years. Most commonly reported symptoms were exertional dyspnea (78%) and fatigue (73%). Only 40% (n=57/142) had signs of volume overload. Left-sided HF signs were rare. Patients with clinical HF before ARVC/D diagnosis (n=31) were older (P=0.005) and met fewer Task Force Criteria (P=0.013) than those who developed HF after ARVC/D presentation. Female sex (odds ratio, 2.2; 95% confidence interval, 1.21-4.01; P=0.01) and lateral precordial T-wave inversions (odds ratio, 9.87; 95% confidence interval, 1.07-91.1; P=0.043) were associated with increased odds of HF. Additionally, patients with symptomatic LV dysfunction had higher odds of lateral precordial T-wave inversions (odds ratio, 18.4; 95% confidence interval, 2.92-116.18; P=0.002). Patients with HF were more likely to undergo heart transplantation (15/142 versus 1/147; P<0.001) or die during study follow-up period (7 versus 0; P=0.007). HF symptoms, especially exertional dyspnea, are common in ARVC/D; yet, classic left-sided signs are typically absent and less than half have evidence of volume overload. Given the unique predominately right-sided phenotype, a large portion of patients with HF may be under-recognized.

ANKSTYVIEJI KAIRIOJO SKILVELIO ILGOSIOS AŠIES FUNKCIJOS POKYČIAI BEI PROGNOZINĖ REIKŠMĖ SERGANTIEMS BESIMPTOMIU LĖTINIU AORTOS VOŽTUVO NESANDARUMU SU IŠLIKUSIA GERA KAIRIOJO SKILVELIO IŠVARYMO FRAKCIJA

Įvadas. Sergantieji lėtiniu aortos vožtuvo nesandarumu (AVN) ilgus metus nejaučia simptomų, nors miokarde vystosi struktūriniai pokyčiai, ilgainiui lemiantys kairiojo skilvelio (KS) funkcijos blogėjimą. Įprastinis echokardiografinis KS sistolinės funkcijos rodiklis, kaip išvarymo frakcija (IF), dėl lėtinės AVN ydos hemodinaminių ypatybių ilgai išlieka normalus, nors vystosi ankstyvoji ikiklinikinė KS disfunkcija. Darbo tikslas. Nustatyti ankstyvuosius ikiklinikinius KS ilgosios ašies disfunkcijos rodiklius bei jų prognozinę reikšmę sergantiesiems lėtiniu AVN su normalia KS IF. Metodika. Prospektyviniame tyrime dalyvavo besimptomiai pacientai, sergantys lėtiniu vidutiniu ir dideliu AVN su normalia KS IF ir kontrolinė grupė. KS ilgosios ašies funkcija vertinta, atliekant M-režimo ir audinių Doplerio (AD) echokardiografiją (echoKG), išmatuojant dviburio vožtuvo žiedo judesio (DVŽJ) greičius sistolėje ir diastolėje bei DVŽJ amplitudę. Rezultatai. Sergantiems besimptomiu dideliu AVN bendrieji DVŽJ sistoliniai M-režimo ir AD greičiai bei DVŽJ amplitudė buvo statistiškai reikšmingai sumažėję, lyginant su kontroline grupe (4,8±0,86 cm/s vs. 5,47±1,0cm/s; 7,81±1,73 vs. 9,19±1,9 cm/s; 1,39±0,19 vs. 1,53±0,18 cm, p&lt;0,05). Bendrieji ankstyvieji Mrežimo ir AD diastoliniai greičiai reikšmingai buvo sumažėję sergantiems vidutiniu ir sunkiu AVN, lyginant su sveikaisiais (vidutinio AVN grupė: 6,79±2,18 vs. 7,76±1,89cm/s, 9,89±3,30 vs.11,15±2,29cm/s, p&lt;0.05; didelio AVN grupė: 5,57± vs. 7,76±1,89cm/s, 8,14±2,96 vs. 11,15±2,29cm/s, p&lt;0,05). KS ilgosios ašies ankstyvieji diastoliniai greičiai reikšmingai prognozavo simptomų atsiradimą sergantiems lėtiniu besimptomibesimptominiu AVN. Išvados. Sergantiems besimptomiu lėtiniu dideliu AVN, nepaisant išlikusios normalios KS IF, ilgosios ašies funkcijos rodikliai buvo sumažėję ir rodo ikiklinikinę KS disfunkciją bei turi prognozinę reikšmę simptomams atsirasti.

Lactated Ringer's solution in combination with rectal indomethacin for prevention of post-ERCP pancreatitis and readmission: a prospective randomized, double-blinded, placebo-controlled trial

Prospective data have shown the benefit of rectal indomethacin (IND) for preventing post-ERCP pancreatitis (PEP). A recent pilot study demonstrated a lower incidence of PEP after an 8-hour lactated Ringer's solution (LR) infusion. The aim of this study was to evaluate the efficacy of IND with or without bolus LR in patients at high-risk for PEP. In this randomized, double-blinded, placebo-controlled trial we assigned patients to standard normal saline solution (NS)+ placebo, NS+ IND, LR+ placebo, or LR+ IND. Each liter of fluid infusion was completed within 30 minutes. Patients were determined high-risk based established criterion and excluded if they had pancreatitis, contraindications to IND, or signs of volume overload. Our primary outcome was PEP, defined by standardized criterion. Our secondary outcomes were severe acute pancreatitis, localized adverse events, death, length of stay, and readmission. Our sample consisted of 192 patients (48 per group) who completed follow-up at 24 hours and at 30 days post-ERCP. All patients had at least 1 high-risk criterion for PEP, and 56% had >1. PEP occurred in 3 patients (6%) in the LR+ IND versus 10 (21%) in the NS+ placebo group (P= .04). Readmission rates were lower in the LR+ IND group (1 [2%]) versus the NS+ placebo group (6 [13%]; P= .03). No differences were found between the other study groups. There was 1 case of severe pancreatitis (NS+ IND) and 1 case of pseudocyst (LR+ IND). In patients at high risk for PEP, LR+ IND reduced the incidence of PEP and readmission ratescompared with NS+ placebo. (Clinical trial registration number: NCT02641561.).

Long-Term Outcomes in Patients With Aortic Regurgitation and Preserved Left Ventricular Ejection Fraction

BackgroundChronic severe aortic regurgitation (AR) imposes significant volume and pressure overload on the left ventricle (LV), but such patients typically remain in an asymptomatic state for a very long time. ObjectivesThis study sought to examine long-term outcomes in a contemporary group of patients with grade III+ chronic AR and preserved left ventricular ejection fraction (LVEF) and the value of aortic valve (AV) surgery on long-term survival. We also wanted to reassess the threshold of LV dimension, beyond which mortality significantly increases. MethodsThe authors studied 1,417 such patients (mean 54 ± 16 years of age, 75% men) seen between 2002 and 2010. Clinical data were obtained and Society of Thoracic Surgeons (STS) score was calculated. The primary endpoint was mortality. ResultsMean STS score was 5.5% ± 8%, and mean LVEF was 57 ± 4%, whereas 1,228 patients (87%) were asymptomatic, and 93 patients (7%) had indexed LV end-systolic dimension (iLVESD) ≥2.5 cm/m2. At 6.6 ± 3 years, 933 patients (66%) underwent AV surgery (36% isolated AV surgery, 16% concomitant coronary bypass, and 58% aortic replacement), and 262 patients (19%) died. In-hospital postoperative mortality was 2% (0.6% in isolated AV surgery). On multivariate Cox survival analysis, compared to the group of iLVESD <2.5 cm/m2 and no AV surgery, the 2 groups of iLVESD <2.5 cm/m2 with AV surgery and iLVESD ≥2.5 cm/m2 with AV surgery were associated with improved survival (hazard ratios: 0.62 and 0.42, respectively; both p < 0.01). Survival of patients who underwent AV surgery was similar to that of an age- and sex-matched U.S. population with 96% of deaths occurring in those with iLVESD <2.5 cm/m2. ConclusionsAt a high-volume experienced center, patients with grade III or greater AR and preserved LVEF demonstrated significantly improved long-term survival following AV surgery. The risk of death significantly increased at a lower LV dimension threshold than previously described.

Bioelectrical impedance vector analysis in the critically ill: cool tool or just another 'toy'?

Assessment of volume and hydration status is far from easy and therefore technology such as bioelectrical impedance vector analysis (BIVA) may complement our examination techniques. This study highlights the fact that clinical assessment of volume balance and BIVA may correlate, but whether the routine use of BIVA will avoid significant volume overload in the critically ill remains unknown. Further studies are needed but at the moment appear a little way off.

Continuous ultrafiltration in acute decompensated heart failure: current issues and future directions.

Most patients hospitalized for acutely decompensated heart failure (ADHF) present with symptoms and signs of volume overload, which are also associated with high rates of death and re-hospitalization. Several studies have investigated the possible use of extracorporeal ultrafiltration in the management of ADHF, evaluating potential clinical benefits in terms of hospitalization and survival rates versus those of conventional diuretic therapy. Though ultrafiltration remains an extremely appealing therapeutic option for patients with AHDF, some of the most recent studies have reported conflicting results. Differences in the selection of study population, heterogeneity of the indications for the use of ultrafiltration, disparity in the ultrafiltration protocols, and high variability in the pharmacologic therapies used for the control group could explain some of these contradictory findings. The purpose of the present review is to provide an overview and an update on the mechanisms and clinical effects of ultrafiltration and on currently available evidence supporting its use in ADHF.

Managing hypercalcaemia and hypocalcaemia in cancer patients

Hypercalcaemia is commonly associated with cancer which is usually advanced and portends a poor prognosis. Hypocalcaemia is more often seen as a complication of therapy aimed at reducing skeletal morbidity rather than an effect of the cancer itself. We present an overview of calcium disorders in malignant disease. A significant proportion of patients who have a cancer and become hypercalcaemic have an alternative cause for their hypercalcaemia.Evidence for the use of loop diuretics is lacking, and such agents should not be routinely used unless significant volume overload occurs during rehydration. Bisphosphonates are generally established as first-line therapy after volume expansion with saline. As knowledge of bone biology increases, there is interest in the use of the mAb denosumab, for the management refractory hypercalcaemia. Knowledge of the vitamin D status, and supplementation of vitamin D, may reduce the risk of hypocalcaemia when potent antiresorptive medications are being used. Calcium disorders can be predicted in many tumour types and with antiresorptive therapy. A logical approach to prevention and management of these imbalances should be incorporated into cancer patient care.

Sodium Removal and Peritoneal Dialysis Modalities: No Differences With Optimal Prescription of Icodextrin

Continuous ambulatory peritoneal dialysis (CAPD) has been considered as a more efficient modality for sodium removal than automated peritoneal dialysis (APD), due to the longer dwell times and the sodium sieving phenomenon. However, because studies regarding sodium removal in peritoneal dialysis (PD) report rather controversial results and carry various methodological flaws, it remains uncertain whether they offer enough significant information regarding PD prescription and therapy. The aim of the present observational cross-sectional study was to evaluate the impact of the optimal prescription of CAPD and APD, regarding solute clearances and daily ultrafiltrate, on daily sodium removal. Forty-six (46) patients aged 52.3 ± 14 years were studied. Twenty-six (26) patients were subjected to CAPD, and 20 patients were subjected to APD. Ten (10) patients per group were prescribed icodextrin for the long dwell to achieve optimal adequacy and ultrafiltration (UF) targets. CAPD patients removed a higher, albeit not statistically significant, daily amount of sodium (131.7 ± 98.2 mmol) compared with APD patients (79.4 ± 129.2 mmol). Their Kt/V urea was lower (1.48 ± 0.3 vs. 2.17 ± 0.33, P < 0.05), and there were no differences on daily UF (1119 ± 533 vs. 1005 ± 517 mL). In both groups, icodextrin use for the long dwell resulted in equal sodium removal with that of patients not prescribed icodextrin. Our results, derived from an unselected PD population, indicate that although classic CAPD may be more efficient for sodium removal than APD, the use of icodextrin as an adjuvant for higher daily UF not only increases solute clearance but also removes more sodium for both modalities. In addition, calculations of sodium removal in PD do not seem to benefit the everyday clinical practice, provided that PD patients can achieve the adequacy targets and present optimal daily UF without signs of volume overload.

Is this patient a candidate for ultrafiltration?

In Brief Similar to dialysis, ultrafiltration is a type of renal replacement therapy that may be indicated for patients with heart failure who have significant volume overload despite outpatient diuretic therapy. Here's what you need to know about this therapy, which can be safely managed in any telemetry unit or even in an outpatient treatment area that has appropriately trained personnel.

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Introduction: Continuous infusions (CI) of loop diuretics provide constant delivery of drug to site of action in the kidney, resulting in a continuous natriuretic effect. Data supporting the efficacy/safety of CI of high dose bumetanide (CIHDB) are sparse. A detailed review of a single institution’s experience will help fill the gap in literature. Hypothesis: CIHDB are effective in inducing diuresis and achieving dry weight in critically ill cardiac and cardiothoracic (CT) surgery patients (pts) with significant volume overload without causing new-onset acute renal failure. Methods: A retrospective electronic/paper chart review of all pts treated with a CIHDB at a single institution was performed. Pts receiving an infusion of 1-2 mg/hr bumetanide with sufficient data were included. Pts were excluded if the infusion rate remained <1 mg/hr or if receiving concomitant renal replacement therapy (RRT) or aquaphoresis. Data collected included weights, dosing of intermittent loop diuretics and CIHDB, urine output (UOP), serum creatinine, need for RRT. Kidney Disease: Improving Global Outcomes (KDIGO) criteria were used to stage severity of acute kidney injury (AKI). Results: Thirty-eight pts treated for a mean of 53 hours were included. All pts received at least one dose of IV loop diuretics in the 24 hours preceding CIHDB, while 74% received a bolus of bumetanide IV 2-4 mg within 2 hours preceding CIHDB. Prior to initiation of CIHDB, mean volume overload was +6.2 kg (-1.8 to 11.8 kg) above dry weight; mean UOP was 0.9 cc/kg/hr (0.2-3 cc/kg/hr). After the first 24 hours, UOP increased to 1.6 cc/kg/hr (p<0.001) and to 1.9 cc/kg/hr (p<0.001) after the second 24 hours. Mean weight loss following CIHDB was 5.2 kg. At baseline, 16 (42%) had stage 1-2 AKI. Following CIDHB, 6 (38%) of these pts progressed to stage 3 AKI, but were maintained on CIHDB for 3-48 hours prior to RRT. After CIHDB, an additional 12 pts had stage 1-2 AKI, 10 of which were new onset. Conclusions: CIHDB is effective at improving UOP and achieving significant weight loss in critically ill cardiac and CT surgery pts. Optimizing diuretic therapy may potentially delay/avoid RRT. Further randomized, controlled studies are needed to support these results.

Treating volume overload in acutely decompensated heart failure: established and novel therapeutic approaches.

Most patients hospitalized for acutely decompensated heart failure (ADHF) present with symptoms and signs of volume overload, which is also associated with substantially high rates of death and rehospitalization in ADHF. To review the recent experimental and clinical evidence on existing therapeutic algorithms and investigational drugs used for the treatment of volume overload in ADHF patients. A systematic search of peer-reviewed publications was performed on Medline and EMBASE from January 1990 to March 2012. The results of unpublished trials were obtained from presentations at national and international meetings. Apart from intrinsic renal insufficiency and neurohormonal activation, volume overload through venous congestion may be the primary haemodynamic factor triggering the worsening of renal function in ADHF patients. It is well known that heart and kidneys are closely interrelated and an acute or chronic disorder in one organ may induce acute or chronic dysfunction in the other organ. Established therapeutic strategies, (e.g. loop diuretics, vasodilators, and inotropes), are sometimes associated with limited clinical success due to tolerance and the need for frequent up titration of the doses in order to achieve the desired effect. That leads to an increasing interest in novel options, such as the use of adenosine A1 receptor antagonists, vasopressin antagonists, and renal-protective dopamine. Initial clinical trials have shown quite encouraging results in some heart failure subpopulations but have failed to demonstrate a clear beneficial role of these agents. On the other hand, ultrafiltration appears to be a more promising therapeutic procedure that will improve volume regulation, while preserving renal and cardiac function. Further clinical studies are required in order to determine their net effect on renal function and potential cardiovascular outcomes. Until then, management of volume overload in ADHF patients remains a challenge for the clinicians.

Serum Alkaline Phosphatase Levels and Left Ventricular Diastolic Dysfunction in Patients with Advanced Chronic Kidney Disease

Background: High levels of alkaline phosphatase (ALP) have been associated with increased mortality in patients with advanced chronic kidney disease (CKD). We hypothesize that elevated ALP could be partly explained by subclinical liver congestion related to left ventricular diastolic dysfunction. Methods: Doppler echocardiography was performed in 68 patients with advanced CKD followed up for a median of 2.1 years. Time-averaged levels of ALP and γ-glutamyl transferase (GGT) were compared between patients with and without diastolic dysfunction. We also evaluated the effect of intensifying diuretic treatment on ALP levels in a small group of 16 patients with high ALP and signs of volume overload. Results: ALP correlated significantly (p < 0.001) with GGT but not with parathyroid hormone (p = 0.09). Patients with diastolic dysfunction showed higher ALP (p = 0.01), higher GGT (p = 0.03) and lower albumin (p = 0.04). The highest values of ALP were observed in patients with diastolic dysfunction plus pulmonary hypertension (p = 0.01). Intensifying diuretic therapy in a subgroup of patients with signs of fluid overload induced a significant reduction in body weight, GGT (p < 0.001) and ALP levels (p < 0.001). Conclusions: Elevated ALP in patients with advanced CKD could be partly explained by subclinical liver congestion related to left ventricular diastolic dysfunction, hypervolemia or both. The worse prognosis of these patients could be explained by their myocardial damage.

Role of Bioimpedance Vectorial Analysis in Cardio-Renal Syndromes

The cardio-renal syndromes (CRS) are the result of complex bidirectional organ cross-talk between the heart and kidney, with tremendous overlap of diseases such as coronary heart disease, heart failure (HF), and renal dysfunction in the same patient. Volume overload plays an important role in the pathophysiology of CRS. The appropriate treatment of overhydration, particularly in HF and in chronic kidney disease, has been associated with improved outcomes and blood pressure control. Clinical examination alone is often insufficient for accurate assessment of volume status because significant volume overload can exist even in the absence of peripheral or pulmonary edema on physical examination or radiography. Bioelectrical impedance techniques increasingly are being used in the management of patients with HF and those on chronic dialysis. These methods provide more objective estimates of volume status in such patients. Used in conjunction with standard clinical assessment and biomarkers such as the natriuretic peptides, bioimpedance analysis may be useful in guiding pharmacologic and ultrafiltration therapies and subsequently restoring such patients to a euvolemic or optivolemic state. In this article, we review the use of these techniques in CRS.

A Multicenter, Randomized, Double-blind, Placebo-controlled Study of Tolvaptan Monotherapy Compared to Furosemide and the Combination of Tolvaptan and Furosemide in Patients With Heart Failure and Systolic Dysfunction

Background Increased vasopressin levels may be present in patient with chronic heart failure (HF) and contribute to pathophysiology through effects on the vasopressin V2 receptor. The presence of background diuretic therapy may confound evaluations of vasopressin receptor antagonists (VRA). Methods and Results Eligible patients had HF (New York Heart Association Class II-III), systolic dysfunction (left ventricular ejection fraction ≤0.40) and signs of congestion (eg, edema, rales). At screening, patients were removed from baseline diuretic therapy and placed on a low-sodium diet (2 g/day). After a 2-day run-in period, 83 patients were randomized to placebo (n = 21), monotherapy with the vasopressin V2 receptor antagonist tolvaptan (TLV) 30 mg (n = 20), monotherapy with furosemide 80 mg (FURO, n = 22) or both TLV 30 mg and FURO 80 mg (n = 20) once daily for 7 days. Patients were on standard background therapy and not fluid-restricted throughout the study. A decrease in body weight of −1.37 ± 1.61, −0.54 ± 1.59, and −1.13 ± 1.49 kg was observed versus baseline for TLV, FURO, and TLV+FURO, respectively, at day 8. At the same point, the placebo group showed a body weight increase of +0.72 ± 2.42 kg versus baseline ( P = .0006 for TLV versus placebo). Increases in urine volume from baseline were greater with TLV alone (2646 ± 1503 mL/24 hours) than with FURO (894 ± 853 mL/24 hours, P < .001), or PLC (423 ± 786 mL/24 hours, P < .001), and similar to TLV+FURO (2585 ± 2119 mL/24 hours). An increase in serum sodium within the normal range was also observed in TLV-treated patients ( P < .02 versus placebo; P < .01 versus FURO). No changes in serum potassium, other laboratory values, or blood pressure were observed. TLV therapy was well tolerated. Conclusions In patients with HF and signs of volume overload, TLV monotherapy without concomitant loop diuretic therapy reduced body weight when compared to placebo without adverse changes in serum electrolytes, during a sodium restricted diet while on background medications including angiotensin-converting enzyme inhibitors and β-blockers.