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John J V Mcmurray - One of the best experts on this subject based on the ideXlab platform.
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reduced loop Diuretic use in patients taking sacubitril valsartan compared with enalapril the paradigm hf trial
European Journal of Heart Failure, 2019Co-Authors: Orly Vardeny, Jessica Kachadourian, Brian Claggett, Akshay S. Desai, Milton Packer, Martin P Lefkowitz, Karl Swedberg, Michael R Zile, John J V McmurrayAbstract:Aims: To assess differences in Diuretic dose requirements in patients treated with sacubitril/valsartan compared with enalapril in the Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure (PARADIGM‐HF) trial. Methods and results: Overall, 8399 patients with New York Heart Association class II–IV heart failure and reduced LVEF were randomized to sacubitril/valsartan 200 mg bid or enalapril 10 mg twice daily. Loop Diuretic doses were assessed at baseline, 6, 12, and 24 months, and furosemide dose equivalents were calculated via multiplication factors (2x for torsemide and 40x for bumetanide). Percentages of participants with reductions or increases in loop Diuretic dose were determined. At baseline, 80.8% of participants were taking any Diuretics (n = 6290 for loop Diuretics, n = 496 for other Diuretics); of those, recorded dosage data for loop Diuretics were available on 5487 participants. Mean baseline furosemide equivalent doses were 48.2 mg for sacubitril/valsartan and 49.6 mg for enalapril (P = 0.25). Patients treated with sacubitril/valsartan were more likely to reduce Diuretic dose and less likely to increase Diuretic dose relative to those randomized to enalapril at 6, 12, 24 months post‐randomization, with an overall decreased Diuretic use of 2.0% (P = 0.02), 4.1% (P < 0.001), and 6.1% (P < 0.001) at 6, 12, and 24 months, respectively, with similar findings in an on‐treatment analysis. Conclusion: Treatment with sacubitril/valsartan was associated with more loop Diuretic dose reductions and fewer dose increases compared with enalapril, suggesting that treatment with sacubitril/valsartan may reduce the requirement for loop Diuretics relative to enalapril in patients with heart failure with reduced ejection fraction.
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loop Diuretics renal function and clinical outcome in patients with heart failure and reduced ejection fraction
European Journal of Heart Failure, 2016Co-Authors: Kevin Damman, John G F Cleland, John Kjekshus, John Wikstrand, Michel Komajda, Hans Wedel, F Waagstein, John J V McmurrayAbstract:Aim We aimed to study the relationships of loop Diuretic dose with renal function and clinical outcomes in patients with chronic heart failure (HF). Methods and results Loop Diuretic dose at baseline was recorded in patients included in the Controlled Rosuvastatin Multinational Trial in Heart Failure (CORONA). The relationship to change in estimated glomerular filtration rate (eGFR) over time and to the first occurrence of the composite outcome of cardiovascular (CV) death or hospitalization owing to HF was examined in propensity score matched cohorts. Of the 5011 patients, 2550, 745, and 449 were receiving >80 mg (high), 41–80 mg (medium) and ≤40 mg (low) of loop Diuretics in furosemide equivalent daily dosages, respectively, which were used to assemble 229, 385, and 1045 pairs of propensity-matched high, medium, and low dose cohorts. Compared with matched no loop Diuretic groups, eGFR declined 0.3 ± 0.2, 0.3 ± 0.3 and 1.2 ± 0.5 mL/min/1.73 m2/year in the low-, medium-, and high-dose groups, respectively. Compared with matched no loop Diuretic groups, hazard ratios (HR) (95% confidence intervals) for outcome associated with low-, medium- and high-dose groups were 1.71 (1.41–2.06), 1.99 (1.50–2.64), and 2.94 (1.95–4.41), respectively. Higher loop Diuretic dose was particularly associated with increased risk for hospitalization owing to HF: HR 4.80 (2.75–8.37), P < 0.001. Conclusions The use of loop Diuretics was associated with a slightly greater rate of decline in eGFR, which did not vary significantly by Diuretic dose.Loop Diuretic dose was associated with higher risks of (CV) mortality and predominantly hospitalization owing to HF, which appeared to be higher among those receiving higher daily doses.
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loop Diuretic dose adjustments after a hospitalization for heart failure insights from ascend hf
European Journal of Heart Failure, 2015Co-Authors: John J V Mcmurray, Vic Hasselblad, Christopher M Oconnor, Adam D Devore, Robert J Mentz, Paul W Armstrong, Justin A EzekowitzAbstract:AimsLoop Diuretics are a cornerstone of heart failure (HF) treatment, but data regarding Diuretic dose adjustments after a HF hospitalization and the association with subsequent outcomes are limited. This study was therefore conducted to determine these factors. Methods and resultsWe analysed data from 6119 patients enrolled in ASCEND-HF, examining the association between loop Diuretic use at the time of discharge, compared with admission, and the composite outcome of 30-day HF re-hospitalization or all-cause mortality. The majority of patients, 3921 (64%), were taking a loop Diuretic on admission. At discharge, 3411 (56%) patients were prescribed higher doses compared with admission, including 1867 (31%) initiating daily outpatient Diuretics; 1912 (31%) had no dose change and 795 (13%) were prescribed lower doses compared with admission. Initiation of an oral loop Diuretic at discharge was independently associated with better 30-day outcomes compared with no dose change [adjusted odds ratio (OR) 0.51, 95% confidence interval (CI) 0.37-0.68]. However, for patients that were already established on a loop Diuretic prior to admission, change in the dose at discharge was not associated with improved outcomes compared with no dose change (adjusted OR 0.92, 95% CI 0.79-1.07). ConclusionsIn a large multinational clinical trial, 56% of patients hospitalized with HF were either initiated on a daily loop Diuretic at discharge or discharged on higher doses compared with admission. In patients established on Diuretics prior to hospitalization, we found no association between changes to chronic doses at discharge and improved outcomes, whereas initiation of loop Diuretic therapy was associated with better outcomes compared with no dose change.
Jeffrey M Testani - One of the best experts on this subject based on the ideXlab platform.
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pathophysiology of Diuretic resistance and its implications for the management of chronic heart failure
Hypertension, 2020Co-Authors: Christopher S Wilcox, Jeffrey M Testani, Bertram PittAbstract:Diuretic resistance implies a failure to increase fluid and sodium (Na+) output sufficiently to relieve volume overload, edema, or congestion, despite escalating doses of a loop Diuretic to a ceiling level (80 mg of furosemide once or twice daily or greater in those with reduced glomerular filtration rate or heart failure). It is a major cause of recurrent hospitalizations in patients with chronic heart failure and predicts death but is difficult to diagnose unequivocally. Pharmacokinetic mechanisms include the low and variable bioavailability of furosemide and the short duration of all loop Diuretics that provides time for the kidneys to restore Diuretic-induced Na+ losses between doses. Pathophysiological mechanisms of Diuretic resistance include an inappropriately high daily salt intake that exceeds the acute Diuretic-induced salt loss, hyponatremia or hypokalemic, hypochloremic metabolic alkalosis, and reflex activation of the renal nerves. Nephron mechanisms include tubular tolerance that can develop even during the time that the renal tubules are exposed to a single dose of Diuretic, or enhanced reabsorption in the proximal tubule that limits delivery to the loop, or an adaptive increase in reabsorption in the downstream distal tubule and collecting ducts that offsets ongoing blockade of Na+ reabsorption in the loop of Henle. These provide rationales for novel strategies including the concurrent use of Diuretics that block these nephron segments and even sequential nephron blockade with multiple Diuretics and aquaretics combined in severely Diuretic-resistant patients with heart failure.
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Diuretic therapy for patients with heart failure jacc state of the art review
Journal of the American College of Cardiology, 2020Co-Authors: Michael G Felker, Wilfried Mullens, David H Ellison, Zachary L Cox, Jeffrey M TestaniAbstract:Expansion of extracellular fluid volume is central to the pathophysiology of heart failure. Increased extracellular fluid leads to elevated intracardiac filling pressures, resulting in a constellation of signs and symptoms of heart failure referred to as congestion. Loop Diuretics are one of the cornerstones of treatments for heart failure, but in contrast to other therapies, robust clinical trial evidence to guide the use of Diuretics is sparse. A nuanced understanding of renal physiology and Diuretic pharmacokinetics is essential for skillful use of Diuretics in the management of heart failure in both the inpatient and outpatient settings. Diuretic resistance, defined as an inadequate quantity of natriuresis despite an adequate Diuretic regimen, is a major clinical challenge that generally portends a poor prognosis. In this review, the authors discuss the fundamental mechanisms and physiological principles that underlie the use of Diuretic therapy and the available data on the optimal use of Diuretics.
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Diuretic Strategies for Loop Diuretic Resistance in Acute Heart Failure: The 3T Trial
JACC. Heart failure, 2019Co-Authors: Zachary L Cox, Rebecca Hung, Daniel J. Lenihan, Jeffrey M TestaniAbstract:Abstract Objectives This study compared combination Diuretic strategies in acute heart failure (AHF) complicated by Diuretic resistance (DR). Background Combination Diuretic regimens to overcome loop DR are commonly used but with limited evidence. Methods This study was a randomized, double-blinded trial in 60 patients hospitalized with AHF and intravenous (IV) loop DR. Patients were randomized to oral metolazone, IV chlorothiazide, or tolvaptan therapy. All patients received concomitant high-dose IV infusions of furosemide. The primary outcome was 48-h weight loss. Results The cohort exhibited DR prior to enrollment, producing 1,188 ± 476 ml of urine in 12 h during high-dose loop Diuretic therapy (IV furosemide: 612 ± 439 mg/day). All 3 interventions significantly improved Diuretic efficacy (p Conclusions In this moderately sized DR trial, weight loss was excellent with the addition of metolazone, IV chlorothiazide, or tolvaptan to loop Diuretics, without a detectable between-group difference. (Comparison of Oral or Intravenous Thiazides vs. tolvaptan in Diuretic Resistant Decompensated Heart Failure [3T]; NCT02606253)
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the use of Diuretics in heart failure with congestion a position statement from the heart failure association of the european society of cardiology
Почки - Počki, 2019Co-Authors: Wilfried Mullens, Kevin Damman, Pieter Martens, W Wilson H Tang, Velipekka Harjola, Alexandre Mebazaa, Hanspeter Brunnerla Rocca, Jeffrey M Testani, Francesco Orso, Patrick RossignolAbstract:The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of Diuretic therapy. The appropriate use of Diuretics however remains challenging, especially when worsening renal function, Diuretic resistance and electrolyte disturbances occur. This position paper focuses on the use of Diuretics in heart failure with congestion. The manuscript addresses frequently encountered challenges, such as (i) evaluation of congestion and clinical euvolaemia, (ii) assessment of Diuretic response/resistance in the treatment of acute heart failure, (iii) an approach towards stepped pharmacologic Diuretic strategies, based upon Diuretic response, and (iv) management of common electrolyte disturbances. Recommendations are made in line with available guidelines, evidence and expert opinion.
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dominance of furosemide for loop Diuretic therapy in heart failure time to revisit the alternatives
Journal of the American College of Cardiology, 2013Co-Authors: Behnood Bikdeli, Jeffrey M Testani, Steven G Coca, Kelly M Strait, Kumar Dharmarajan, Chohreh Partovian, Nancy Kim, Usman Khan, Harlan M KrumholzAbstract:To the Editor: Diuretics are a mainstay of treatment in both chronic and acute decompensated heart failure (HF). Studies during the 1990s and early 2000s show that roughly 90% of HF patients receive at least 1 class of Diuretics, particularly a loop Diuretic, for management of chronic ([1,2][1]) or
Glenn M Chertow - One of the best experts on this subject based on the ideXlab platform.
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central venous pressure and the risk of Diuretic associated acute kidney injury in patients after cardiac surgery
American Heart Journal, 2020Co-Authors: Ian E Mccoy, Maria E Montezrath, Glenn M Chertow, Tara I ChangAbstract:Background When prescribing Diuretics in the postcardiac surgical intensive care unit (ICU), clinicians may use central venous pressure (CVP) to assess volume status and the risk of acute kidney injury (AKI). In this study, we examined how the risk of Diuretic-associated AKI varied with CVP in patients undergoing cardiac surgery. Methods We used the Medical Information Mart for Intensive Care database to study adults admitted to the postcardiac surgical ICU at an urban, academic medical center between 2001 and 2012. We examined the odds of AKI per 1–mm Hg increase in CVP among patients receiving intravenous loop Diuretics using multivariable adjusted logistic regression. We examined the risk of AKI among patients with Diuretic use (vs nonuse) across tertiles of CVP using inverse probability treatment weighting. Results Among 4,164 patients receiving intravenous loop Diuretics, the adjusted odds of subsequent AKI were 1.11 (95% CI 1.08-1.13) times higher per mm Hg increase in mean CVP. This association was log-linear across the entire range of CVPs observed. In the analysis of Diuretic use (n = 5,396), the adjusted risk ratio for AKI with Diuretic use (vs nonuse) was 1.33 (95% CI 1.21-1.47) and did not materially differ across tertile of CVP. Conclusions Higher rather than lower CVP is an independent marker of AKI risk. The risk of AKI associated with Diuretic use may not be influenced by CVP. Novel methods of assessing volume status and AKI risk are needed to guide patient selection for Diuretic therapy.
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patterns of Diuretic use in the intensive care unit
PLOS ONE, 2019Co-Authors: Ian E Mccoy, Glenn M Chertow, Tara Hsin I ChangAbstract:Purpose To inform future outcomes research on Diuretics, we sought to describe modern patterns of Diuretic use in the intensive care unit (ICU), including Diuretic type, combination, and dosing. We also investigated two possible quality improvement targets: furosemide dosing in renal impairment and inclusion of an initial bolus with continuous furosemide infusions. Materials and methods In this descriptive study, we retrospectively studied 46,037 adult ICU admissions from a publicly available database of patients in an urban, academic medical center. Results Diuretics were employed in nearly half (49%, 22,569/46,037) of ICU admissions. Mechanical ventilation, a history of heart failure, and admission to the post-cardiac surgery unit were associated with a higher frequency of Diuretic use. Combination use of different Diuretic classes was uncommon. Patients with severely impaired kidney function were less likely to receive Diuretics. Furosemide was by far the most common Diuretic given and the initial intravenous dose was only 20 mg in more than half of ICU admissions. Among patients treated with a continuous infusion, 30% did not receive a bolus on the day of infusion initiation. Conclusions Patterns of Diuretic use varied by patient-specific factors and by ICU type. Diuretic dosing strategies may be suboptimal.
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Diuretics mortality and nonrecovery of renal function in acute renal failure
JAMA, 2002Co-Authors: Ravindra L Mehta, Maria T Pascual, Sharon Soroko, Glenn M ChertowAbstract:Context Acute renal failure is associated with high mortality and morbidity. Diuretic agents continue to be used in this setting despite a lack of evidence supporting their benefit. Objective To determine whether the use of Diuretics is associated with adverse or favorable outcomes in critically ill patients with acute renal failure. Design Cohort study conducted from October 1989 to September 1995. Patients and setting A total of 552 patients with acute renal failure in intensive care units at 4 academic medical centers affiliated with the University of California. Patients were categorized by the use of Diuretics on the day of nephrology consultation and, in companion analyses, by Diuretic use at any time during the first week following consultation. Main outcome measures All-cause hospital mortality, nonrecovery of renal function, and the combined outcome of death or nonrecovery. Results Diuretics were used in 326 patients (59%) at the time of nephrology consultation. Patients treated with Diuretics on or before the day of consultation were older and more likely to have a history of congestive heart failure, nephrotoxic (rather than ischemic or multifactorial) origin of acute renal failure, acute respiratory failure, and lower serum urea nitrogen concentrations. With adjustment for relevant covariates and propensity scores, Diuretic use was associated with a significant increase in the risk of death or nonrecovery of renal function (odds ratio, 1.77; 95% confidence interval, 1.14-2.76). The risk was magnified (odds ratio, 3.12; 95% confidence interval, 1.73-5.62) when patients who died within the first week following consultation were excluded. The increased risk was borne largely by patients who were relatively unresponsive to Diuretics. Conclusions The use of Diuretics in critically ill patients with acute renal failure was associated with an increased risk of death and nonrecovery of renal function. Although observational data prohibit causal inference, it is unlikely that Diuretics afford any material benefit in this clinical setting. In the absence of compelling contradictory data from a randomized, blinded clinical trial, the widespread use of Diuretics in critically ill patients with acute renal failure should be discouraged.
Kevin Damman - One of the best experts on this subject based on the ideXlab platform.
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higher doses of loop Diuretics limit uptitration of angiotensin converting enzyme inhibitors in patients with heart failure and reduced ejection fraction
Clinical Research in Cardiology, 2020Co-Authors: Jozine Ter Maaten, Kevin Damman, Pieter Martens, Kenneth Dickstein, Piotr Ponikowski, Stefan D Anker, Chim C Lang, Nilesh J SamaniAbstract:Loop Diuretics are frequently prescribed to patients with heart failure and reduced ejection fraction (HFrEF) for the treatment of congestion; however, they might hamper uptitration of inhibitors of the renin–angiotensin system. Loop Diuretic dose at baseline was recorded in 2338 patients with HFrEF enrolled in BIOSTAT-CHF, an international study of HF patients on loop Diuretic therapy who were eligible for uptitration of angiotensin-converting enzyme inhibitors (ACEi)/mineralocorticoid receptor antagonists (MRA). The association between loop Diuretic dose and uptitration of ACEi/MRA to percentage of target dose was adjusted for a previously published model for likelihood of uptitration and a propensity score. Baseline median loop Diuretic dose was 40 [40–100] mg of furosemide or equivalent. Higher doses of loop Diuretics were associated with higher NYHA class and higher levels of NT-proBNP, more severe signs and symptoms of congestion, more frequent MRA use, and lower doses of ACEi reached at 3 and 9 months (all P < 0.01). After propensity adjustment, higher doses of loop Diuretics remained significantly associated with poorer uptitration of ACEi (Beta per log doubling of loop Diuretic dose: − 1.66, P = 0.021), but not with uptitration of MRAs (P = 0.758). Higher doses of loop Diuretics were independently associated with an increased risk of all-cause mortality or HF hospitalization [HR per doubling of loop Diuretic dose: 1.06 (1.01–1.12), P = 0.021]. Higher doses of loop Diuretics limited uptitration of ACEi in patients with HFrEF and were associated with a higher risk of death and/or HF hospitalization, independent of their lower likelihood of uptitration and higher baseline risk. This figure was created with images adapted from Servier Medical Art licensed under a Creative Commons Attribution 3.0
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Higher doses of loop Diuretics limit uptitration of angiotensin-converting enzyme inhibitors in patients with heart failure and reduced ejection fraction
Clinical Research in Cardiology, 2020Co-Authors: Jozine Ter Maaten, Kevin Damman, Pieter Martens, Kenneth Dickstein, Piotr Ponikowski, Chim Lang, Stefan D Anker, Nilesh J Samani, Gerasimos Filippatos, John ClelandAbstract:Background: Loop Diuretics are frequently prescribed to patients with heart failure and reduced ejection fraction (HFrEF) for the treatment of congestion; however, they might hamper uptitration of inhibitors of the renin-angiotensin system. Methods: Loop Diuretic dose at baseline was recorded in 2338 patients with HFrEF enrolled in BIOSTAT-CHF, an international study of HF patients on loop Diuretic therapy who were eligible for uptitration of angiotensin-converting enzyme inhibitors (ACEi)/mineralocorticoid receptor antagonists (MRA). The association between loop Diuretic dose and uptitration of ACEi/MRA to percentage of target dose was adjusted for a previously published model for likelihood of uptitration and a propensity score. Results: Baseline median loop Diuretic dose was 40 [40-100] mg of furosemide or equivalent. Higher doses of loop Diuretics were associated with higher NYHA class and higher levels of NT-proBNP, more severe signs and symptoms of congestion, more frequent MRA use, and lower doses of ACEi reached at 3 and 9 months (all P < 0.01). After propensity adjustment, higher doses of loop Diuretics remained significantly associated with poorer uptitration of ACEi (Beta per log doubling of loop Diuretic dose: - 1.66, P = 0.021), but not with uptitration of MRAs (P = 0.758). Higher doses of loop Diuretics were independently associated with an increased risk of all-cause mortality or HF hospitalization [HR per doubling of loop Diuretic dose: 1.06 (1.01-1.12), P = 0.021]. Conclusions: Higher doses of loop Diuretics limited uptitration of ACEi in patients with HFrEF and were associated with a higher risk of death and/or HF hospitalization, independent of their lower likelihood of uptitration and higher baseline risk.
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Higher doses of loop Diuretics limit uptitration of angiotensin-converting enzyme inhibitors in patients with heart failure and reduced ejection fraction.
2020Co-Authors: Jozine Ter Maaten, Kevin Damman, Pieter Martens, Kenneth Dickstein, Piotr Ponikowski, Stefan D Anker, Nilesh J Samani, Chim C Lang, Gerasimos FilippatosAbstract:BACKGROUND: Loop Diuretics are frequently prescribed to patients with heart failure and reduced ejection fraction (HFrEF) for the treatment of congestion; however, they might hamper uptitration of inhibitors of the renin-angiotensin system. METHODS: Loop Diuretic dose at baseline was recorded in 2338 patients with HFrEF enrolled in BIOSTAT-CHF, an international study of HF patients on loop Diuretic therapy who were eligible for uptitration of angiotensin-converting enzyme inhibitors (ACEi)/mineralocorticoid receptor antagonists (MRA). The association between loop Diuretic dose and uptitration of ACEi/MRA to percentage of target dose was adjusted for a previously published model for likelihood of uptitration and a propensity score. RESULTS: Baseline median loop Diuretic dose was 40 [40-100] mg of furosemide or equivalent. Higher doses of loop Diuretics were associated with higher NYHA class and higher levels of NT-proBNP, more severe signs and symptoms of congestion, more frequent MRA use, and lower doses of ACEi reached at 3 and 9 months (all P
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the use of Diuretics in heart failure with congestion a position statement from the heart failure association of the european society of cardiology
Почки - Počki, 2019Co-Authors: Wilfried Mullens, Kevin Damman, Pieter Martens, W Wilson H Tang, Velipekka Harjola, Alexandre Mebazaa, Hanspeter Brunnerla Rocca, Jeffrey M Testani, Francesco Orso, Patrick RossignolAbstract:The vast majority of acute heart failure episodes are characterized by increasing symptoms and signs of congestion with volume overload. The goal of therapy in those patients is the relief of congestion through achieving a state of euvolaemia, mainly through the use of Diuretic therapy. The appropriate use of Diuretics however remains challenging, especially when worsening renal function, Diuretic resistance and electrolyte disturbances occur. This position paper focuses on the use of Diuretics in heart failure with congestion. The manuscript addresses frequently encountered challenges, such as (i) evaluation of congestion and clinical euvolaemia, (ii) assessment of Diuretic response/resistance in the treatment of acute heart failure, (iii) an approach towards stepped pharmacologic Diuretic strategies, based upon Diuretic response, and (iv) management of common electrolyte disturbances. Recommendations are made in line with available guidelines, evidence and expert opinion.
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loop Diuretics renal function and clinical outcome in patients with heart failure and reduced ejection fraction
European Journal of Heart Failure, 2016Co-Authors: Kevin Damman, John G F Cleland, John Kjekshus, John Wikstrand, Michel Komajda, Hans Wedel, F Waagstein, John J V McmurrayAbstract:Aim We aimed to study the relationships of loop Diuretic dose with renal function and clinical outcomes in patients with chronic heart failure (HF). Methods and results Loop Diuretic dose at baseline was recorded in patients included in the Controlled Rosuvastatin Multinational Trial in Heart Failure (CORONA). The relationship to change in estimated glomerular filtration rate (eGFR) over time and to the first occurrence of the composite outcome of cardiovascular (CV) death or hospitalization owing to HF was examined in propensity score matched cohorts. Of the 5011 patients, 2550, 745, and 449 were receiving >80 mg (high), 41–80 mg (medium) and ≤40 mg (low) of loop Diuretics in furosemide equivalent daily dosages, respectively, which were used to assemble 229, 385, and 1045 pairs of propensity-matched high, medium, and low dose cohorts. Compared with matched no loop Diuretic groups, eGFR declined 0.3 ± 0.2, 0.3 ± 0.3 and 1.2 ± 0.5 mL/min/1.73 m2/year in the low-, medium-, and high-dose groups, respectively. Compared with matched no loop Diuretic groups, hazard ratios (HR) (95% confidence intervals) for outcome associated with low-, medium- and high-dose groups were 1.71 (1.41–2.06), 1.99 (1.50–2.64), and 2.94 (1.95–4.41), respectively. Higher loop Diuretic dose was particularly associated with increased risk for hospitalization owing to HF: HR 4.80 (2.75–8.37), P < 0.001. Conclusions The use of loop Diuretics was associated with a slightly greater rate of decline in eGFR, which did not vary significantly by Diuretic dose.Loop Diuretic dose was associated with higher risks of (CV) mortality and predominantly hospitalization owing to HF, which appeared to be higher among those receiving higher daily doses.
Paul A. Sobotka - One of the best experts on this subject based on the ideXlab platform.
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ultrafiltration is associated with fewer rehospitalizations than continuous Diuretic infusion in patients with decompensated heart failure results from unload
Journal of Cardiac Failure, 2010Co-Authors: Maria Rosa Costanzo, Mitchell T Saltzberg, Mariell Jessup, John R Teerlink, Paul A. SobotkaAbstract:Abstract Background Compare outcomes of ultrafiltration (UF) versus standard intravenous (IV) Diuretics by continuous infusion or bolus injection in volume overloaded heart failure (HF) patients. In the Ultrafiltration versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated heart Failure (UNLOAD) study, UF produced greater fluid reduction and fewer HF rehospitalizations than IV Diuretics in 200 hospitalized HF patients. Outcomes may be due to greater fluid removal, but UF removes more sodium/unit volume than Diuretics. Methods and Results Outcomes of 100 patients randomized to UF were compared with those of patients randomized to standard IV Diuretic therapy with continuous infusion (32) or bolus injections (68). Choice of Diuretic therapy was by the treating physician. Forty-eight hour weight loss (kg): 5.0 ± 3.1 UF, 3.6 ± 3.5 continuous infusion, and 2.9 ± 3.5 bolus Diuretics ( P = .001 UF versus bolus Diuretic; P > .05 for the other comparisons). Net fluid loss (L): 4.6 ± 2.6 UF, 3.9 ± 2.7 continuous infusion, and 3.1 ± 2.6 bolus Diuretics ( P P > .05 for the other comparisons). At 90 days, rehospitalizations plus unscheduled visits for HF/patient (rehospitalization equivalents) were fewer in UF group (0.65 ± 1.36) than in continuous infusion (2.29 ± 3.23; P = .016 versus UF) and bolus Diuretics (1.31 ± 1.87; P = .050 versus UF) groups. No serum creatinine differences occurred between groups up to 90 days. Conclusions Despite similar fluid loss with UF and continuous Diuretic infusion, fewer HF rehospitalizations equivalents occurred only with UF. Removal of isotonic fluid by UF compared with hypotonic urine by Diuretics more effectively reduces total body sodium in congested HF patients.
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loop Diuretics can cause clinical natriuretic failure a prescription for volume expansion
Congestive Heart Failure, 2009Co-Authors: Syed S Ali, Paul A. Sobotka, Chad C Olinger, Thom G Dahle, Matthew C Bunte, Donnevan Blake, Andrew J BoyleAbstract:Ultrafiltration enhances volume removal and weight reduction vs Diuretics. However, their differential impact on total body sodium, potassium, and magnesium has not been described. Fifteen patients with congestion despite Diuretic therapy had urine electrolytes measured after a Diuretic dose. Ultrafiltration was initiated and ultrafiltrate electrolytes were measured. The urine sodium after Diuretics (60±47 mmol/L) was less than in the ultrafiltrate (134±8.0 mmol/L) (P=.000025). The urine potassium level after Diuretics (41±23 mmol/L) was greater than in the ultrafiltrate (3.7±0.6 mmol/L) (P=.000017). The urine magnesium level after Diuretics (5.2±3.1 mg/dL) was greater than in the ultrafiltrate (2.9±0.7 mg/dL) (P=.017). In acute decompensated heart failure patients with congestion despite Diuretic therapy, Diuretics are poor natriuretics and cause significant potassium and magnesium loss. Ultrafiltration extracts more sodium while sparing potassium and magnesium. The sustained clinical benefits of ultrafiltration compared with Diuretics may be partly related to their disparate effects on total body sodium, potassium, and magnesium, in addition to their differential efficacy of volume removal.
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early ultrafiltration in patients with decompensated heart failure and Diuretic resistance
Journal of the American College of Cardiology, 2005Co-Authors: Maria Rosa Costanzo, Mitchell T Saltzberg, Jeanne Osullivan, Paul A. SobotkaAbstract:Objectives We sought to determine if ultrafiltration before intravenous (IV) Diuretics in patients with decompensated heart failure and Diuretic resistance results in euvolemia and early discharge without hypotension or worsening renal function. Background Heart failure patients with renal insufficiency and Diuretic resistance have increased hospital mortality and length of stay. Peripheral veno-venous ultrafiltration may re-establish euvolemia and Diuretic responsiveness. Methods Ultrafiltration was initiated within 4.7 ± 3.5 h of hospitalization and before IV Diuretics in 20 heart failure patients with volume overload and Diuretic resistance (age 74.5 ± 8.2 years; 75% ischemic disease; ejection fraction 31 ± 15%) and continued until euvolemia. Re-evaluation was each hospital day, at 30 days, and at 90 days. Results A total of 8,654 ± 4,205 ml were removed with ultrafiltration. Twelve patients (60%) were discharged in ≤3 days. One patient was readmitted in 30 days. Weight (p = 0.006), Minnesota Living with Heart Failure scores (p = 0.003), and Global Assessment (p = 0.00003) improved after ultrafiltration and at 30 and 90 days. Median B-type natriuretic peptide levels decreased after ultrafiltration (from 1,230 pg/ml to 788 pg/ml) and at 30 days (815 pg/ml) (p = 0.035). Blood pressure, renal function, and medications were unchanged. Conclusions In heart failure patients with volume overload and Diuretic resistance, ultrafiltration before IV Diuretics effectively and safely decreases length of stay and readmissions. Clinical benefits persist at three months.
