Multinephron Segment Diuretic Therapy to Overcome Diuretic Resistance in Acute Heart Failure: A Single-Center Experience |
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| Affiliation: | 1. Department of Pharmacy Practice, Lipscomb University College of Pharmacy, Nashville, Tennessee;2. Department of Pharmacy, Vanderbilt University Medical Center, Nashville, Tennessee;3. Division of Nephrology and Hypertension, Vanderbilt University Medical Center, Nashville, Tennessee;4. Division of Nephrology and Hypertension, Henry Ford Hospital, Detroit, Michigan;5. Division of Nephrology and Hypertension, Wayne State University, Detroit, Michigan;6. Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee;7. Division of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut;1. Department of Medicine and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina;2. Division of Cardiovascular Medicine, Vanderbilt Heart and Vascular Institute, Nashville, Tennesee.;1. Zena and Michael A. Wiener Cardiovascular Institute and Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA;2. Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA;1. The Division of Internal Medicine, University of Washington, Seattle, Washington;2. Center for Outcomes Research and Evaluation, Yale New Haven Health Services Corporation, New Haven, Connecticut;3. Section of Cardiology, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut;4. Department of Health Administration and Policy, University of New Haven, West Haven, Connecticut;1. Department of Medicine, Veterans Affairs Medical Center, Washington, DC;2. Department of Cardiology, MedStar Washington Hospital Center, Washington, DC;3. Department of Medicine, Georgetown University, Washington, DC;4. Department of Cardiology, Attikon University Hospital, Athens, Greece;5. Department of Cardiology, National Kapodistrian University of Athens, Athens, Greece;6. Uniformed Services University, Washington, DC;7. Department of Medicine, University of California, San Francisco, California;8. College of Population Health, Thomas Jefferson University, Philadelphia, Pennsylvania;9. Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama;10. Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow; National Heart & Lung Institute, Imperial College London, Glasgow, UK;11. Department of Medicine, Veterans Affairs Medical Center, Providence, Rhode Island;12. Department of Medicine, Brown University, Providence, Rhode Island;13. Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama;14. Department of Medicine, University of California, Los Angeles, California;1. University of Utah Health Sciences Center, Salt Lake City, Utah;2. Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina;3. Saint Luke''s Mid America Heart Institute/UMKC, Kansas City MO |
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| Abstract: | BackgroundThe concept of multinephron segment diuretic therapy (MSDT) has been recommended in severe diuretic resistance with only expert opinion and case-level evidence. The purpose of this study was to investigate the safety and efficacy of MSDT, combining 4 diuretic classes, in acute heart failure (AHF) complicated by diuretic resistance.Methods and ResultsA retrospective analysis was conducted in patients hospitalized with AHF at a single medical center who received MSDT, including concomitant carbonic anhydrase inhibitor, loop, thiazide, and mineralocorticoid receptor antagonist diuretics. Subjects served as their own controls with efficacy evaluated as urine output and weight change before and after MSDT. Serum chemistries, renal replacement therapies, and in-hospital mortality were evaluated for safety. Patients with severe diuretic resistance before MSDT were analyzed as a subcohort. A total of 167 patients with AHF and diuretic resistance received MSDT. MSDT was associated with increased median 24-hour urine output in the first day of therapy compared with the previous day (2.16 L [0.95–4.14 L] to 3.08 L [1.74–4.86 L], P = .003) in the total cohort and in the Severe diuretic resistance cohort (0.91 L [0.43–1.43 L] to 2.08 L [1.13–3.96 L], P < .001). The median cumulative weight loss at day 7 or discharge was –7.4 kg (–15.3 to –3.4 kg) (P = .02). Neither serum sodium, chloride, potassium, bicarbonate, or creatinine changed significantly relative to baseline (P > .05 for all).ConclusionsIn an AHF cohort with diuretic resistance, MSDT was associated with increased diuresis without changes in serum chemistries or kidney function. Prospective studies of MSDT in AHF and diuretic resistance are warranted. |
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