Natriuresis-Guided Diuretic Therapy for Acute Heart Failure: A Systematic Review and Meta-Analysis of Diuretic Efficacy

Acute heart failure is a major cause of hospitalization and is associated with high morbidity and mortality. Effective decongestion is central to management, yet conventional clinical markers of diuretic response are subjective and may delay therapy optimization. Natriuresis-guided diuretic therapy provides an objective, rapid method for assessing response by adjusting treatment according to urinary sodium excretion. This systematic review and meta-analysis evaluated randomized and non-randomized controlled trials comparing natriuresis-guided therapy with standard care in adults hospitalized with acute heart failure. Primary outcomes were natriuresis and diuresis; secondary outcomes included weight loss, length of hospital stay, hypotension, and hypokalemia. Four trials involving 831 patients were included. Compared with standard care, natriuresis-guided therapy significantly increased natriuresis at 24 hours [mean difference (MD), 83.66 mmol] and 48 hours (MD, 132.27 mmol), and increased 48-hour diuresis (MD, 1.35 L). Hospital length of stay was reduced by 0.80 days. There were no significant differences in hypotension, hypokalemia, or weight loss between groups. Sensitivity analyses confirmed the robustness of these findings. Natriuresis-guided diuretic therapy enhances early decongestion and shortens hospitalization without increasing adverse events, representing a promising biomarker-driven approach to acute heart failure management.