Serial direct sodium removal with loop diuretic withdrawal in heart failure patients improved diuretic response from 81 mmol at baseline to 223 mmol (p<0.001).
Does serial direct sodium removal with diuretic withdrawal improve diuretic response in patients with heart failure and diuretic resistance?
Serial direct sodium removal with loop diuretic withdrawal is feasible and significantly improves diuretic response and cardiorenal parameters in patients with heart failure and diuretic resistance.
Absolute Event Rate: 223% vs 81%
p-value: p=<0.001
AIMS: Loop diuretics may exacerbate cardiorenal syndrome (CRS) in heart failure (HF). Direct sodium removal (DSR) using the peritoneal membrane, in conjunction with complete diuretic withdrawal, may improve CRS and diuretic resistance. METHODS AND RESULTS: Patients with HF requiring high-dose loop diuretics were enrolled in two prospective, single-arm studies: RED DESERT (n = 8 euvolaemic patients), and SAHARA (n = 10 hypervolaemic patients). Loop diuretics were withdrawn, and serial DSR was utilized to achieve and maintain euvolaemia. At baseline, participants required a median 240 mg (interquartile range IQR 200-400) oral furosemide equivalents/day, which was withdrawn in all participants during DSR (median time of DSR 4 weeks IQR 4-6). Diuretic response (queried by formal 40 mg intravenous furosemide challenge and 6 h urine sodium quantification) increased substantially from baseline (81 ± 37 mmol) to end of DSR (223 ± 71 mmol, p < 0.001). Median time to re-initiate diuretics was 87 days, and the median re-initiation dose was 8% (IQR 6-10%) of baseline. At 1 year, diuretic dose remained substantially below baseline (30 IQR 7.5-40 mg furosemide equivalents/day). Multiple dimensions of kidney function such as filtration, uraemic toxin excretion, kidney injury, and electrolyte handling improved (p < 0.05 for all). HF-related biomarkers including N-terminal pro-B-type natriuretic peptide, carbohydrate antigen-125, soluble ST2, interleukin-6, and growth differentiation factor-15 (p < 0.003 for all) also improved. CONCLUSIONS: In patients with HF and diuretic resistance, serial DSR therapy with loop diuretic withdrawal was feasible and associated with substantial and persistent improvement in diuretic resistance and several cardiorenal parameters. If replicated in randomized controlled studies, DSR may represent a novel therapy for diuretic resistance and CRS. CLINICAL TRIAL REGISTRATION: RED DESERT (NCT04116034), SAHARA (NCT04882358).
Rao et al. (Sun,) conducted a other in Heart failure and diuretic resistance (n=18). Serial direct sodium removal (DSR) with loop diuretic withdrawal vs. Baseline was evaluated on Diuretic response (6 h urine sodium quantification after 40 mg IV furosemide challenge) (p=<0.001). Serial direct sodium removal with loop diuretic withdrawal in heart failure patients improved diuretic response from 81 mmol at baseline to 223 mmol (p<0.001).