Loop Diuretic Therapy in Heart Failure: The Need for Solid Evidence on a Fluid Issue

Chiong, Jun R.; Cheung, Rebecca J

doi:10.1002/clc.20771

Cited by 46 publications

(39 citation statements)

References 54 publications

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“…These agents represent a double-edged sword as they may resolve congestion but worsen renal perfusion by arterial underfilling and heightened activation of the sympathetic and RAAS leading to type 1 CRS (99).…”

Section: Cardiac and Renal Fibrosismentioning

confidence: 99%

Cardiorenal Syndrome Type 1

Ronco

Cicoira

McCullough

2012

Journal of the American College of Cardiology

328

131

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Cardiorenal syndrome (CRS) type 1 is characterized as the development of acute kidney injury (AKI) and dysfunction in the patient with acute cardiac illness, most commonly acute decompensated heart failure (ADHF). There is evidence in the literature supporting multiple pathophysiological mechanisms operating simultaneously and sequentially to result in the clinical syndrome characterized by a rise in serum creatinine, oliguria, diuretic resistance, and in many cases, worsening of ADHF symptoms. The milieu of chronic kidney disease has associated factors including obesity, cachexia, hypertension, diabetes, proteinuria, uremic solute retention, anemia, and repeated subclinical AKI events all work to escalate individual risk of CRS in the setting of ADHF. All of these conditions have been linked to cardiac and renal fibrosis. In the hospitalized patient, hemodynamic changes leading to venous renal congestion, neurohormonal activation, hypothalamic-pituitary stress reaction, inflammation and immune cell signaling, systemic endotoxemic exposure from the gut, superimposed infection, and iatrogenesis all contribute to CRS type 1. The final common pathway of bidirectional organ injury appears to be cellular, tissue, and systemic oxidative stress that exacerbate organ function. This review explores in detail the pathophysiological pathways that put a patient at risk and then effectuate the vicious cycle now recognized as CRS type 1.

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Section: Cardiac and Renal Fibrosismentioning

confidence: 99%

Cardiorenal Syndrome Type 1

Ronco

Cicoira

McCullough

2012

Journal of the American College of Cardiology

328

131

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“…Diuretics are essential in treating fluid balance, blood pressure control, prevention of hyperkalemia and urine amount regulation in CKD population456. However, several studies have reported negative outcomes of diuretic usage on renal function, mortality, and hospitalization in patients with heart failure7891011. In acute kidney injury (AKI), loop diuretics exert no significant effect on renal recovery, the need for dialysis, or mortality12131415.…”

mentioning

confidence: 99%

Hyponatremia is Associated with Fluid Imbalance and Adverse Renal Outcome in Chronic Kidney Disease Patients Treated with Diuretics

Lim

Tsai

Lin

et al. 2016

Sci Rep

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Chronic kidney disease (CKD) is frequently complicated with hyponatremia, probably because of fluid overload or diuretic usage. Hyponatremia in CKD population is associated with increased mortality, but the effect on renal outcome was unknown. We investigated whether hyponatremia is associated with fluid status and is a prognostic indicator for adverse outcomes in a CKD cohort of 4,766 patients with 1,009 diuretic users. We found that diuretic users had worse clinical outcomes compared with diuretic non-users. Hyponatremia (serum sodium <135 mEq/L) was associated with excessive volume and volume depletion, measured as total body water by bioimpedance analysis, in diuretic users, but not in diuretic non-users. Furthermore, in Cox survival analysis, hyponatremia was associated with an increased risk for renal replacement therapy (hazard ratio, 1.45; 95% CI, 1.13–1.85, P < 0.05) in diuretic users, but not in diuretic non-users (P for interaction <0.05); restricted cubic spline model also showed a similar result. Hyponatremia was not associated with all-cause mortality or cardiovascular event whereas hypernatremia (serum sodium >141 mEq/L) was associated with an increased risk for all-cause mortality. Thus, hyponatremia is an indicator of fluid imbalance and also a prognostic factor for renal replacement therapy in CKD patients treated with diuretics.

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“…Recent studies have found that diuretic usage is a predictor of mortality in patients with heart failure [57,58]. Tolvaptan's ability to increase the excretion of free water and ameliorate volume overload suggests that it may be a good treatment option for patients with heart failure as implied by the results of ACTIV in CHF and EVEREST trials.…”

Section: Drug Profilementioning

confidence: 95%

Update on tolvaptan for the treatment of hyponatremia

Dasta¹,

Chiong

Christian

et al. 2012

Expert Review of Pharmacoeconomics & Outcomes Research

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Tolvaptan is a member of a new class of drugs, called the vaptans, that antagonize receptors of the neurohormone arginine vasopressin. From a clinical perspective, tolvaptan has been shown to be efficacious in the treatment of hyponatremia, whether it is idiopathic or disease related, and it may have a more favorable benefit/risk profile than other treatment modalities. From an economic perspective, tolvaptan is an expensive drug for treating hyponatremia, but recent economic cost-offset models provide evidence that tolvaptan can be cost effective. The cost-effectiveness of tolvaptan is driven by reduced healthcare resource usage and hospitalization costs. More comparative research of tolvaptan versus other pharmacotherapies and analyses of patients treated with tolvaptan in the real world are needed to better determine the benefits of tolvaptan usage to patient outcome, and more accurately assess its value in the treatment of hyponatremia, an independent predictor of morbidity, mortality and cost.

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Loop Diuretic Therapy in Heart Failure: The Need for Solid Evidence on a Fluid Issue

Cited by 46 publications

References 54 publications

Cardiorenal Syndrome Type 1

Cardiorenal Syndrome Type 1

Hyponatremia is Associated with Fluid Imbalance and Adverse Renal Outcome in Chronic Kidney Disease Patients Treated with Diuretics

Update on tolvaptan for the treatment of hyponatremia

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