Efficacy and safety of natriuresis-guided diuresis in acute decompensated heart failure: a meta-analysis

Abstract Introduction Acute decompensated heart failure (ADHF) is characterized by sudden worsening of heart failure symptoms and is the leading cause of hospitalization in older patients. It is associated with extremely poor health outcomes, with rehospitalization and mortality rates reaching up to 50% in the first six months. Intravenous diuretics remain the cornerstone of ADHF management and have been associated with a mortality benefit in this patient population. However, diuretic therapy is challenging given the varying diuretic response and increased risk of adverse events including electrolyte abnormalities and acute kidney injury (AKI). Traditional methods of assessing diuretic response such as urine output and weight loss are often unreliable and are associated with an increased risk of under-or over-diuresis. Spot urine sodium has emerged as an effective marker of assessing diuretic response and can be used to guide further dosage adjustments. Purpose This meta-analysis aims to evaluate the efficacy and safety of natriuresis-guided diuresis compared to the standard of care in patients with ADHF. Methods Online databases including PubMed, Cochrane Library, and Web of Science were searched. Outcomes measured included all-cause mortality, change in congestion score, AKI, hypokalemia, and 48-hour diuresis. These outcomes were reported as risk ratio (RR) for categorical outcomes and mean difference (MD) for continuous outcomes with a random effects model using 95% confidence intervals (CI). Results Three studies with 771 patients (mean age 71±14, 67% males) were selected. Natriuresis-guided diuresis was associated with a lower risk of AKI (RR=0.51 95% CI: 0.27, 0.97, p=0.04) and increased 48-hour diuresis (MD=1.36 95% CI: 0.91, 1.81, p0.00001). There was no difference in the risk of all-cause mortality (RR=0.92 95% CI: 0.60, 1.41, p=0.70), change in congestion score (MD=-1.10 95% CI: -2.96, 0.76, p=0.25), and hypokalemia (OR=0.99 95% CI: 0.50, 1.97, p=0.98). Conclusion Natriuresis-guided diuresis was associated with a lower risk of AKI and a greater 48-hour diuresis compared to standard of care. However, there was no difference in the risk of all-cause mortality, change in congestion score, or hypokalemia. These results suggest that natriuresis-guided diuresis may enhance diuresis while preserving renal function. However, further studies including randomized controlled trials are needed to confirm these findings.Forest plots of the meta-analysis.