The impact of volume and sodium chloride supplementation on diuretic response during decongestion of decompensated heart failure patients

Background For many years, fluid and sodium restriction have been considered an essential strategy for achieving effective decongestion in acute heart failure (AHF), but this paradigm has recently been questioned. This analysis aims to evaluate and compare the effectiveness of three different fluid strategies for decongestion: no fluid, fluid with sodium/chloride, and fluid without sodium/chloride in AHF. Methods and results This post-hoc analysis of two prospective, single-center, mechanistic studies included 55 patients with AHF and fluid overload. All patients received standardized furosemide dosing. A total of 21 patients received a continuous infusion of 0.9% NaCl (83 mL/h), 19 patients received 5% glucose (83 mL/h), and 15 did not receive any fluids. The primary outcome is urine volume and natriuresis at 6 hours after loop diuretic administration. There was a significant difference in cumulative (6 hours) net natriuresis between patients receiving fluid therapy (n=40) and those without fluid therapy (n=15) (139 [66-264] mmol vs. 79 [15-144]mmol, p=0.043). There was no significant difference in cumulative net diuresis between these groups (1170 [880-1890]mL vs. 1010 [475-1270]mL, p = 0.078), respectively. The NaCl group had a better diuretic response when compared to the glucose and no fluids groups (absolute: 1980 [1620-3150]mL vs. 1510 [1075-2175]mL vs. 1010 [475-1270]mL, p<0.001, net: 1480 [1120-2650]mL vs. 1010 [575-1675]mL vs. 1010 [475-1270]mL, p=0.019, respectively) but the difference in natriuresis did not meet statistical significance (p=0.126). Conclusions Intravenous fluid replacement during decongestion in patients with AHF was associated with increased net natriuresis and a trend toward higher urine output, with a significant augmentation of diuresis with sodium chloride supplementation.