Loop diuretic efficiency: a metric of diuretic responsiveness with prognostic importance in acute decompensated heart failure.
Pubmed ID: 24379278
Pubmed Central ID: PMC4386906
Journal: Circulation. Heart failure
Publication Date: 03/01/2014
Affiliation: Department of Internal Medicine.
MeSH Terms: Humans, Male, Female, Pennsylvania, Middle Aged, Heart Failure, Treatment Outcome, Prospective Studies, Cause of Death, Prognosis, Follow-Up Studies, Patient Discharge, Survival Rate, Hospital Mortality, Glomerular Filtration Rate, Acute Disease, Dose-Response Relationship, Drug, Sodium Potassium Chloride Symporter Inhibitors, Diuresis, Injections, Intravenous
Grants: K23 HL114868, K24 DK090203, L30 HL115790, 1K23HL114868, K24DK090203, L30HL115790
Authors: Testani JM, Brisco MA, Tang WH, Parikh CR, Turner JM, Spatz ES, Bellumkonda L
Cite As: Testani JM, Brisco MA, Turner JM, Spatz ES, Bellumkonda L, Parikh CR, Tang WH. Loop diuretic efficiency: a metric of diuretic responsiveness with prognostic importance in acute decompensated heart failure. Circ Heart Fail 2014 Mar 1;7(2):261-70. Epub 2013 Dec 30.
BACKGROUND: Rather than the absolute dose of diuretic or urine output, the primary signal of interest when evaluating diuretic responsiveness is the efficiency with which the kidneys can produce urine after a given dose of diuretic. As a result, we hypothesized that a metric of diuretic efficiency (DE) would capture distinct prognostic information beyond that of raw fluid output or diuretic dose. METHODS AND RESULTS: We independently analyzed 2 cohorts: (1) consecutive admissions at the University of Pennsylvania (Penn) with a primary discharge diagnosis of heart failure (n=657) and (2) patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness (ESCAPE) data set (n=390). DE was estimated as the net fluid output produced per 40 mg of furosemide equivalents, then dichotomized into high versus low DE based on the median value. There was only a moderate correlation between DE and both intravenous diuretic dose and net fluid output (r(2)≤0.26 for all comparisons), indicating that DE was describing unique information. With the exception of metrics of renal function and preadmission diuretic therapy, traditional baseline characteristics, including right heart catheterization variables, were not consistently associated with DE. Low DE was associated with worsened survival even after adjusting for in-hospital diuretic dose, fluid output, in addition to baseline characteristics (Penn: hazards ratio [HR], 1.36; 95% confidence interval [CI], 1.04-1.78; P=0.02; ESCAPE: HR, 2.86; 95% CI, 1.53-5.36; P=0.001). CONCLUSIONS: Although in need of validation in less-selected populations, low DE during decongestive therapy portends poorer long-term outcomes above and beyond traditional prognostic factors in patients hospitalized with decompensated heart failure.