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Tan Z, Liu Y, Hong K. The association between serum chloride and mortality in ICU patients with heart failure: The impact of bicarbonate. Int J Cardiol 2024; 399:131672. [PMID: 38141731 DOI: 10.1016/j.ijcard.2023.131672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/27/2023] [Accepted: 12/18/2023] [Indexed: 12/25/2023]
Abstract
OBJECTIVE To assess whether serum chloride predicts risk of death in intensive care unit (ICU) patients with heart failure (HF) and the effect of bicarbonate on the efficacy of serum chloride in predicting risk of death in ICU patients. METHODS A total of 9364 HF patients hospitalized in the ICU were enrolled. Patients were divided into hypochloremia (< 96 mEq/L), normal chloride (96-108 mEq/L), and hyperchloremia (> 108 mEq/L) groups. Similarly, we divided the serum bicarbonate level into three groups: low bicarbonate (< 22 mEq/L), medium bicarbonate (22-26 mEq/L), and high bicarbonate (> 26 mEq/L). The outcome of this study was in-hospital mortality. Then, we analyzed the association between abnormal serum chloride and mortality according to the category of serum bicarbonate and assessed the interaction effect. Restricted cubic spline (RCS) was used to show possible nonlinear associations. RESULTS In the overall study population, hypochloremia was associated with a higher risk of in-hospital mortality than normal chloride (odds ratio [OR] 1.54, 95% confidence interval [CI] 1.26-1.86, P < 0.001), hyperchloremia was not significantly related to in-hospital mortality (OR 1.00, 95% CI 0.85-1.19, P = 0.962). However, a linear association between serum chloride and in-hospital mortality was found in the low and normal bicarbonate groups (all P for nonlinear >0.05). CONCLUSIONS Hypochloremia is associated with in-hospital mortality and longer hospital stay in critically ill patients with HF. In addition, risk of death in the low and medium serum bicarbonate groups decreased with increasing serum chloride level.
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Affiliation(s)
- Zhaochong Tan
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Yang Liu
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China
| | - Kui Hong
- Department of Cardiovascular Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China; Department of Genetic Medicine, the Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi 330006, China; Jiangxi Key Laboratory of Molecular Medicine, Nanchang, Jiangxi 330006, China.
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Kataoka H. Mechanistic insights into chloride-related heart failure progression according to the plasma volume status. ESC Heart Fail 2022; 9:2044-2048. [PMID: 35384366 PMCID: PMC9065841 DOI: 10.1002/ehf2.13927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 03/04/2022] [Accepted: 03/28/2022] [Indexed: 11/11/2022] Open
Abstract
Aims Two types of heart failure (HF) progression were recently proposed on the basis of an increased vs. non‐increased serum chloride concentration. The applicability of this concept to real‐world HF pathophysiology requires further investigation. The present study evaluated the mechanisms of HF progression to a different type according to changes in the estimated plasma volume status (ePVS). Methods and results Data from 47 patients (32% men; 78.2 ± 9.7 years of age) with stable to worsening HF (37.5 ± 16 days) were analysed. Physical examination, standard blood tests, and b‐type natriuretic peptide (BNP) measurements were conducted. The ePVS was calculated as follows: ePVS (dL/g) = [100 − haematocrit (%)]/[haemoglobin (g/dL)]. For the study subjects as a whole (n = 47), changes in the ePVS correlated positively with changes in the serum chloride concentration from stable to worsening HF (r = 0.398, P = 0.0056). When divided into two groups of worsening HF with an increased (n = 31) vs. non‐increased serum chloride concentration (n = 16), no significant baseline differences in body weight, serum logBNP, or ePVS were detected between groups. Under worsening HF, the increase in body weight (2.34 ± 1.12 vs. 2.59 ± 1.56 kg, P = 0.57) and logBNP (0.39 ± 0.30 vs. 0.54 ± 0.31 pg/mL, P = 0.13) did not differ between groups, but the increase in the ePVS was smaller in the group with a non‐increased serum chloride concentration compared with that with an increased serum chloride concentration (0.292 ± 0.49 vs. 0.653 ± 0.60 dL/g, P = 0.044). An increase in the %change in ePVS ≥ 10% was less common in patients with a non‐increased chloride concentration (37% vs. 71%, P = 0.03). Patients with a non‐increased serum chloride concentration had more HF signs (3.31 ± 0.79 vs. 2.65 ± 0.71, P = 0.005) and a higher incidence of pulmonary rales (63% vs. 16%, P = 0.0024) than those with an increased serum chloride concentration. Conclusions According to the changes in the ePVS, HF progression may result from a difference between two HF types (i.e. increased vs. non‐increased serum chloride concentration) in the cardiac reserve in response to a given cardiac burden by modulating plasma volume status via the possible tonicity potential of chloride.
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Affiliation(s)
- Hajime Kataoka
- Department of Internal Medicine, Nishida Hospital, Tsuruoka-Nishi-Machi 2-266, Saiki, Oita, 876-0047, Japan
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Kataoka H. Chloride in Heart Failure Syndrome: Its Pathophysiologic Role and Therapeutic Implication. Cardiol Ther 2021; 10:407-428. [PMID: 34398440 PMCID: PMC8555043 DOI: 10.1007/s40119-021-00238-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Indexed: 12/18/2022] Open
Abstract
Until recently, most studies of heart failure (HF) focused on body fluid dynamics through control of the sodium and water balance in the body. Chloride has remained largely ignored in the medical literature, and in clinical practice, chloride is generally considered as an afterthought to the better-known electrolytes of sodium and potassium. In recent years, however, the important role of chloride in the distribution of body fluid has emerged in the field of HF pathophysiology. Investigation of HF pathophysiology according to the dynamics of serum chloride is rational considering that chloride is an established key electrolyte for tubulo-glomerular feedback in the kidney and a possible regulatory electrolyte for body fluid distribution. The present review provides a historical overview of HF pathophysiology, followed by descriptions of the recent attention to the electrolyte chloride in the cardiovascular field, the known role of chloride in the human body, and recent new findings regarding the role of chloride leading to the proposed ‘chloride theory’ hypothesis in HF pathophysiology. Next, vascular and organ congestion in HF is discussed, and finally, a new classification and potential therapeutic strategy are proposed according to the ‘chloride theory’.
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Bellino MC, Massari F, Albanese M, Ursi R, Angelini G, Lisi F, Amato L, Scicchitano P, Guida P, Brunetti ND, Di Serio F, Ciccone MM, Iacoviello M. Baseline and incident hypochloremia in chronic heart failure outpatients: Clinical correlates and prognostic role. Eur J Intern Med 2021; 84:32-37. [PMID: 32896445 DOI: 10.1016/j.ejim.2020.08.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 08/09/2020] [Accepted: 08/20/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Electrolyte serum disorders are associated with poor outcome in chronic heart failure. The aim of this study sought to identify the main driver of incident hypochloremia in chronic HF (CHF) outpatients and to determine the prognostic value of baseline and incident hypochloremia. METHODS Consecutive CHF outpatients were enrolled and clinical, laboratoristic and echocardiographic evaluations were performed at baseline and repeated yearly in a subgroup of patients. Baseline and incident hypochloremia were evaluated. During an up to 5-year follow-up, all-cause mortality was the primary end-point for outcome. RESULTS Among 506 patients enrolled, 120 patients died during follow-up. At baseline, hypochloremia was present in 10% of patients and it was associated with mortality at univariate (HR: 3.25; 95%CI: 2.04-5.18; p<0.001) and at multivariate analysis (HR 2.14; 95%CI: 1.23-3.63; p: 0.005) after correction for well-established CHF prognostic markers. Among patients with repeated evaluations and without baseline hypochloremia, in 13% of these, incident hypochloremia occurred during follow-up and furosemide equivalent daily dose was its first determinant (HR for 1 mg/die: 1.008; 95%CI: 1.004-1.013; p<0.001) at forward stepwise logistic regression analysis. Finally, incident hypochloremia was associated with mortality at univariate (HR: 4.69; 95%CI: 2.69-8.19; p<0.001) as well as at multivariate analysis (HR: 2.97; 95%CI: 1.48-5.94; p: 0.002). CONCLUSIONS In CHF outpatients baseline and incident hypochloremia are independently associated with all-cause mortality, thus highlighting the prognostic role of serum chloride levels which are generally unconsidered. Future studies should evaluate if the strict monitoring and correction of hypochloremia could exert a beneficial effect on prognosis.
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Affiliation(s)
- Maria Consiglia Bellino
- School of Cardiology, "A. Moro" University of Bari, Bari, Italy; University Cardiology Unit, University Policlinic Hospital of Bari, Bari, Italy
| | | | - Miriam Albanese
- School of Cardiology, "A. Moro" University of Bari, Bari, Italy; University Cardiology Unit, University Policlinic Hospital of Bari, Bari, Italy
| | - Raffaella Ursi
- School of Cardiology, "A. Moro" University of Bari, Bari, Italy; University Cardiology Unit, University Policlinic Hospital of Bari, Bari, Italy
| | - Gianmarco Angelini
- School of Cardiology, "A. Moro" University of Bari, Bari, Italy; University Cardiology Unit, University Policlinic Hospital of Bari, Bari, Italy
| | - Francesco Lisi
- School of Cardiology, "A. Moro" University of Bari, Bari, Italy; University Cardiology Unit, University Policlinic Hospital of Bari, Bari, Italy
| | - Luca Amato
- School of Cardiology, "A. Moro" University of Bari, Bari, Italy
| | | | | | - Natale Daniele Brunetti
- Cardiology Unit, Department of Medical and Surgical Science, University of Foggia, Viale Luigi Pinto 1, Foggia, Italy
| | - Francesca Di Serio
- Clinical Pathology Unit, University Policlinic Hospital of Bari, Bari, Italy
| | - Marco Matteo Ciccone
- School of Cardiology, "A. Moro" University of Bari, Bari, Italy; University Cardiology Unit, University Policlinic Hospital of Bari, Bari, Italy
| | - Massimo Iacoviello
- Cardiology Unit, Department of Medical and Surgical Science, University of Foggia, Viale Luigi Pinto 1, Foggia, Italy.
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Kobayashi M, Girerd N, Duarte K, Chouihed T, Chikamori T, Pitt B, Zannad F, Rossignol P. Estimated plasma volume status in heart failure: clinical implications and future directions. Clin Res Cardiol 2021; 110:1159-1172. [PMID: 33409701 DOI: 10.1007/s00392-020-01794-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 12/10/2020] [Indexed: 01/02/2023]
Abstract
Congestion is one of the main predictors of poor outcome in patients with heart failure (HF). Assessing and monitoring congestion is essential for optimizing HF therapy. Among the various available methods, serial measurements of estimated plasma volume (ePVS) using routine blood count and/or body weight (e.g., the Strauss, Duarte, Hakim formulas) may be useful in HF management. Further prospective study is warranted to determine whether ePVS can help optimize decongestion therapy (loop diuretics, mineralocorticoid receptor antagonists, SGLT2i) in various HF settings. This narrative review summarizes the recent evidence supporting the association of ePVS with clinical congestion and outcome(s) and discusses future directions for monitoring ePVS in HF.
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Affiliation(s)
- Masatake Kobayashi
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France
| | - Nicolas Girerd
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France
| | - Kevin Duarte
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France
| | - Tahar Chouihed
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France
| | | | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France
| | - Patrick Rossignol
- Centre d'Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Inserm 1116 and INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Université de Lorraine, Nancy, France.
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Kataoka H. Proposal for New Classification and Practical Use of Diuretics According to Their Effects on the Serum Chloride Concentration: Rationale Based on the "Chloride Theory". Cardiol Ther 2020; 9:227-244. [PMID: 32378135 PMCID: PMC7584720 DOI: 10.1007/s40119-020-00172-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Indexed: 02/06/2023] Open
Abstract
Currently, diuretic therapy for heart failure (HF) pathophysiology is primarily focused on the sodium and water balance. Over the last several years, however, chloride (Cl) has been recognized to have an important role in HF pathophysiology, as both a prognostic marker and a possible central factor regulating the body fluid status. I recently proposed a unifying hypothesis for HF pathophysiology, called the "chloride theory", during HF worsening and recovery, as follows. Chloride is the key electrolyte for regulating both reabsorption of tubular electrolytes and water in the kidney through the renin-angiotensin-aldosterone system and distributing body fluid in each compartment of the body. As changes between the serum Cl concentration and plasma volume are intimately associated with worsening HF and its recovery after decongestive therapy, modulation of the serum Cl concentration by careful selection and combination of various diuretics and their doses could become an attractive therapeutic option for HF. In this review, I will propose a new classification and practical use of diuretics according to their effects on the serum Cl concentration. Diuretic use according to this classification is expected to be a useful strategy for the treatment of patients with HF.
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Kataoka H. Effusion-Serum Chloride Gradient in Heart Failure-Associated Pleural Effusion - Pathophysiologic Implications. Circ Rep 2020; 2:357-363. [PMID: 33693253 PMCID: PMC7932818 DOI: 10.1253/circrep.cr-20-0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Background:
There is scant clinical data of electrolyte analyses in the pleural fluid under heart failure (HF) pathophysiology. Methods and Results:
This study retrospectively analyzed data from 17 consecutive patients who presented with pleural effusion and underwent thoracentesis. A diagnosis of worsening HF was established by clinical criteria (presentation, echocardiography, serum B-type natriuretic peptide, and response to therapy). Samples of non-heparinized pleural fluid and peripheral venous blood, obtained within 2 h of each other, were subjected to biochemical analysis. The source of pleural effusion was determined as transudate or exudate according to Light’s criteria. Fifteen patients (53% men; mean [±SD] age 85±11 years) had HF-associated pleural effusion, 10 of whom had transudative effusion and 5 who had exudative effusion (fulfilling only 1 [n=4] or both [n=1] lactate dehydrogenase criteria). The effusion-serum gradient (calculated by subtracting the serum electrolyte concentration from the effusion electrolyte concentration) was significantly higher for chloride (mean [±SD] 7.4±2.6 mEq/L; range 4–14 mEq/L) than sodium (0.9±1.4 mEq/L; ranging from −1 to 4 mEq/L) and potassium (−0.1±0.3 mEq/L; ranging from −0.8 to 0.2 mEq/L; P<0.001 for each). Conclusions:
In HF-associated pleural effusion, the chloride concentration is higher in the pleural effusion than the serum, indicating that chloride may have an important role in the formation and retention of body fluid in the pleural space.
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Kataoka H, Yoshida Y. Enhancement of the serum chloride concentration by administration of sodium-glucose cotransporter-2 inhibitor and its mechanisms and clinical significance in type 2 diabetic patients: a pilot study. Diabetol Metab Syndr 2020; 12:5. [PMID: 31956343 PMCID: PMC6958611 DOI: 10.1186/s13098-020-0515-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 01/04/2020] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Chloride is a key electrolyte that regulates the body fluid distribution. Accordingly, manipulating chloride kinetics by selecting a suitable diuretic could be an attractive strategy for correcting body fluid dysregulation. Therefore, this study examined the effects and contributing factors of a sodium-glucose cotransporter-2 inhibitor (SGLT2i) on the serum chloride concentration in type 2 diabetic (T2DM) patients without heart failure (HF). METHODS This study was a retrospective single-center observational study that enrolled 10 T2DM/non-HF outpatients for whom the SGLT2i empagliflozin (daily oral dose of 10 mg) was prescribed. Among these 10 patients, 6 underwent detailed clinical testing that included hormonal and metabolic blood tests. RESULTS Empagliflozin treatment for 1-2 months decreased body weight (- 2.69 ± 1.9 kg; p = 0.002) and HbA1c (- 0.88 ± 0.55%; p = 0.0007). The hemoglobin (+ 0.27 ± 0.36 g/dL; p = 0.04) and hematocrit (+ 1.34 ± 1.38%; p = 0.014) values increased, but the serum creatinine concentration remained unchanged. The serum chloride concentration increased from 104 ± 3.23 to 106 ± 2.80 mEq/L (p = 0.004), but the sodium and potassium concentrations did not change. The spot urinary sodium concentration decreased from 159 ± 43 to 98 ± 35 mEq/L (p < 0.02) and the spot urinary chloride tended to decrease (from 162 ± 59 to 104 ± 36 mEq/L, p < 0.08). Both renin and aldosterone tended to be activated (5/6, 83%). The strong organic acid metabolite concentrations of serum acetoacetate (from 42 ± 25 to 100 ± 45 μmol/L, p < 0.02) and total ketone bodies (from 112 ± 64 to 300 ± 177 μmol/L, p < 0.04) increased, but the actual HCO3 - concentration decreased (from 27 ± 2.5 to 24 ± 1.6 mEq/L, p < 0.008). CONCLUSIONS The present study demonstrated that SGLT2i enhances the serum chloride concentration in T2DM patients and suggests that the effect is mediated by the possible following mechanisms: (1) enhanced reabsorption of urinary chloride by aldosterone activation due to blood pressure lowering and blood vessel contraction effects, (2) reciprocal increase in the serum chloride concentration by reducing the serum HCO3 - concentration via a buffering effect of strong organic acid metabolites, and (3) reduced NaHCO3 reabsorption and concurrently enhanced chloride reabsorption in the urinary tubules by inhibiting Na+-H+ exchanger 3 in the renal proximal tubules. Thus, the diuretic SGLT2i induces excessive extravascular fluid to drain into the vascular space by the enhanced vascular "tonicity" caused by the elevated serum chloride concentration.
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Affiliation(s)
- Hajime Kataoka
- Internal Medicine, Nishida Hospital, 2-266 Tsuruoka-Nishi-machi, Saiki, Oita 876-0047 Japan
| | - Yuichi Yoshida
- Department of Endocrinology, Metabolism, Rheumatology and Nephrology, Faculty of Medicine, Oita University, 1-1 Idai-ga-oka, Hasama-machi, Yufu, Oita 879-5593 Japan
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Kataoka H. Comparison of Changes in Plasma Volume and Renal Function between Acetazolamide and Conventional Diuretics: Understanding the Mechanical Differences according to the "Chloride Theory". Cardiology 2019; 145:215-223. [PMID: 31865322 DOI: 10.1159/000504533] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 11/04/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We compared the effects of the chloride-regaining diuretic acetazolamide with those of conventional diuretics on plasma volume, serum electrolytes, and renal function in acutely decompensated heart failure (HF) patients. METHODS A retrospective analysis was performed on the data of 13 patients treated with acetazolamide (Group A) and 13 patients with conventional diuretics (Group B) matched based on diuresis-induced weight reduction (≥1 kg) during resolution of worsening HF. Changes in plasma volume (Strauss formula), renal function, and serum electrolytes under treatment were determined by peripheral blood tests. RESULTS Clinical characteristics at baseline were not different between groups A and B. After diuretic therapy, body weight reduction (-2.23 ± 1.11 vs. -2.22 ± 1.06 kg, p = 0.97) and the number of residual HF-related signs (0.31 ± 0.48 vs. 0.23 ± 0.44, p = 0.67) was not different between groups. After each treatment, the serum chloride concen-tration increased in Group A, but decreased in Group B (+5.31 ± 4.91 vs. - 4.54 ± 4.68 mEq/L, p < 0.0001). Plasma volume (0.63 ± 13.1 vs. -12.1 ± 10.5%, p < 0.01) and renal function determined by changes in serum creatinine concentration (0.048 ± 0.12 vs. 0.21 ± 0.24 mg/dL, p < 0.047) were preserved in Group A compared with Group B. CONCLUSIONS While both groups exhibited equivalent body weight reduction and resolution of HF-related signs after each diuretic treatment, acetazolamide treatment preserved plasma volume and renal function compared to conventional diuretics.
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Acetazolamide as a potent chloride-regaining diuretic: short- and long-term effects, and its pharmacologic role under the 'chloride theory' for heart failure pathophysiology. Heart Vessels 2019; 34:1952-1960. [PMID: 31114959 DOI: 10.1007/s00380-019-01433-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Accepted: 05/15/2019] [Indexed: 01/19/2023]
Abstract
According to the "chloride theory" for heart failure (HF) pathophysiology, manipulation of the serum chloride concentration is an important therapeutic target. This study determined the short- and long-term effects of acetazolamide (Diamox), a potential chloride-regaining diuretic, on peripheral blood, serum electrolytes, and renal function. Effects of low-dose Diamox (250-500 mg/day) were evaluated in 30 HF patients for whom Diamox was added as de-novo/add-on decongestion therapy for acutely worsening HF (n = 18) or as modification therapy for serum hypochloremia in stable HF ( < 100 mEq/L; n = 12). Peripheral hematologic tests were performed at baseline, and at short- ( ≤ 10 days) and long-term ( ~ 60 days) time-points. In all 30 study patients of both groups, the serum chloride concentration increased in the short-term and even further over the long-term. The serum potassium concentration constantly decreased throughout the study period. Both the blood urea nitrogen and serum creatinine concentrations increased in the short-term, but returned to baseline levels over the long-term. Responders to Diamox (n = 13; defined by HF resolution and body weight loss ≥ 1 kg) in the decongestion group exhibited reduced serum b-type natriuretic peptide levels and a markedly increased serum chloride concentration, but the hemoglobin/hematocrit and serum creatinine concentrations did not change after treatment. In conclusion, acetazolamide is a potent candidate "chloride-regaining diuretic" for treating HF patients under the "chloride theory". Its effect to enhance the serum chloride concentration occurred within 10 days and persisted for at least ~ 60 days. Plasma volume and renal function were preserved under adequate diuretic treatment with acetazolamide.
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Kataoka H. Biochemical Determinants of Changes in Plasma Volume After Decongestion Therapy for Worsening Heart Failure. J Card Fail 2019; 25:213-217. [DOI: 10.1016/j.cardfail.2018.09.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 09/20/2018] [Accepted: 09/30/2018] [Indexed: 11/28/2022]
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Kataoka H. Dynamic changes in serum chloride concentrations during worsening of heart failure and its recovery following conventional diuretic therapy: A single-center study. Health Sci Rep 2018; 1:e94. [PMID: 30623047 PMCID: PMC6242367 DOI: 10.1002/hsr2.94] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/08/2018] [Accepted: 09/14/2018] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND AND AIMS Few data are available regarding the dynamic changes in the serum chloride concentrations in heart failure (HF) pathophysiology. The aim of the present study was to investigate changes in the serum chloride concentration under worsening HF and its recovery following conventional diuretic therapy. METHODS Blood test data, including measurements of serum albumin/solutes and b-type natriuretic peptide, at both worsening and recovery of HF status, were obtained from 47 patients with definite HF. RESULTS Ambulatory patients with HF were enrolled and followed up at the outpatient clinic of Nishida Hospital between June 2003 and March 2009. From clinically stable to worsening HF, the serum sodium concentration increased from (mean ± SD) 139 ± 4.1 to 141 ± 5.07 mEq/L (P < 0.05, two-way analysis of variance) and the serum chloride concentration increased from 101 ± 5.36 to 104 ± 5.44 mEq/L (P < 0.01) among all patients. After resolution of worsening HF by treatment with conventional diuretics, both the serum sodium concentration and serum chloride concentration decreased significantly to 138 ± 5.12 and 99.5 ± 5.33 mEq/L, respectively (P < 0.0001 for each). The absolute changes in the serum sodium concentration from clinically stable HF to worsening HF appeared to be lesser than those in the serum chloride concentration (1.70 ± 4.34 vs 2.72 ± 6.02 mEq/L, P = 0.079, t test), but this was not statistically significant. Absolute changes in the serum sodium concentration from worsening HF to its recovery following treatment with conventional diuretics were lesser than those in the serum chloride concentration (-2.87 ± 4.38 vs -4.45 ± 5.23 mEq/L, P = 0.0068, t test). CONCLUSION Under conventional diuretic therapy, greater changes occur in the serum chloride concentration than in the serum sodium concentration under HF state transitions, suggesting that chloride dynamics might contribute more to HF pathophysiology under such therapeutic circumstance.
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Kataoka H. Vasopressin antagonist-like effect of acetazolamide in a heart failure patient: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2018; 2:yty076. [PMID: 31020154 PMCID: PMC6177024 DOI: 10.1093/ehjcr/yty076] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 06/08/2018] [Indexed: 02/05/2023]
Abstract
Background Hyponatraemia is easily corrected by treatment with an oral vasopressin antagonist, but these medications are costly and their use at outpatient clinics is restricted by government-managed insurance in Japan. Acetazolamide could be an alternative diuretic to a vasopressin antagonist. Case Summary An 83-year-old dyspnoeic male patient was emergently admitted to the hospital due to decompensated heart failure (HF), hypotension, and hyperkalaemia-associated sinus arrest with a junctional escape rhythm. Urgent treatment with a noradrenaline drip infusion and a beta stimulant adhesive skin patch promptly restored sinus rhythm with conducted normal QRS complex, which resolved the hypotension. Blood tests on admission revealed moderately elevated b-type natriuretic peptide (BNP, 576 pg/mL), hyponatraemia (128 mEq/L), hypochloraemia (95 mEq/L), hyperkalaemia (5.7 mEq/L), and preserved renal function (creatinine, 1.0 mg/dL) under no cardiovascular medications. Immediately after admission, low-dose oral acetazolamide (500 mg/day) and polystyrene sulfonate-Ca jelly (Argamate, 25 g/day for 3 days) were prescribed to correct the decompensated HF status and electrolyte disturbance. Three days later, both the serum sodium and chloride concentrations had recovered to normal levels (136 mEq/L and 104 mEq/L, respectively), and the serum potassium concentration had decreased to 4.5 mEq/L. Two weeks later, the patient’s HF status became stable and the serum BNP concentration returned to normal (55 pg/mL). Discussion The present case indicates that the classic diuretic of acetazolamide would have a vasopressin blockade-like effect and could be an alternative diuretic to vasopressin antagonists for some proportion of HF patients with hyponatraemia.
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Affiliation(s)
- Hajime Kataoka
- Division of Internal Medicine, Nishida Hospital, Tsuruoka-Nishi-Machi 2-266, Saiki-City, Oita, Japan
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Kataoka H. Changes in red blood cell volume during transition of heart failure status: a reflection of cellular hydration status? Scandinavian Journal of Clinical and Laboratory Investigation 2018; 78:305-311. [PMID: 29703089 DOI: 10.1080/00365513.2018.1466607] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
This study examined how changes in heart failure (HF) status induce changes in the index of erythrocyte hydration based on mean red blood cell volume (MCV). Data from 47 HF patients (32% men; 78.2 ± 9.7 years) that experienced worsening and recovery of HF were analysed. Blood tests included measurements of MCV, albumin, serum solutes and b-type natriuretic peptide (BNP). Among a total of 47 worsening HF events, changes in MCV were positively correlated with changes in body weight (r = 0.31, p = .034), serum sodium (r = 0.417, p = .0036), and chloride (r = 0.457, p = .0012), and negatively correlated with changes in blood urea nitrogen (r= -0.389, p = .0069) and creatinine (r= -0.494, p = .0004). At recovery from worsening of HF by conventional diuretic therapy, change in MCV was positively correlated with the change in body weight (r = 0.457, p = .0012), serum sodium (r = 0.466, p = .001) and chloride (r = 0.484, p = .0006). Multivariate regression analysis demonstrated an independent association between the increase in serum chloride and MCV from stability to worsening of HF (odds ratio [OR] 6.02, 95% confidence interval [CI] 1.09-33.2, p = .039) and the increase or absence of change in serum chloride concentration and preserved MCV after decongestion (OR 11.5, 95% CI 1.53-85.9, p = .017). In conclusion, this study demonstrates that the changes in MCV under transition in HF status do not reflect a change that occurs in parallel with changes in HF-related markers, such as body weight and serum BNP level, but is independently associated with a change in the serum chloride concentration. Whether changes in MCV actually reflect the bodily cellular hydration status warrants further research.
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Vascular expansion during worsening of heart failure: Effects on clinical features and its determinants: Methodological issues to avoid misinterpretation. Int J Cardiol 2018; 254:260. [PMID: 29407105 DOI: 10.1016/j.ijcard.2017.06.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2017] [Accepted: 06/06/2017] [Indexed: 11/20/2022]
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Kataoka H. Proposal for heart failure progression based on the 'chloride theory': worsening heart failure with increased vs. non-increased serum chloride concentration. ESC Heart Fail 2017; 4:623-631. [PMID: 29154432 PMCID: PMC5695179 DOI: 10.1002/ehf2.12191] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2016] [Revised: 04/17/2017] [Accepted: 06/02/2017] [Indexed: 01/30/2023] Open
Abstract
AIMS Chloride (Cl) is an established key electrolyte for the activation of the renin-angiotensin-aldosterone system. Recent studies have shown the serum Cl as a key electrolyte for the regulation of body fluid distribution in heart failure (HF) patients. The clinical differences of worsening HF status according to the changes in serum Cl concentration are unclear. METHODS AND RESULTS Data from 47 chronic HF patients were analysed. Upon worsening HF, each patient exhibited at least two HF-related signs. Blood tests included haemoglobin (Hb), haematocrit (Ht), mean red blood cell volume (MCV), albumin, serum solutes, and b-type natriuretic peptide. The relative change in the plasma volume (%PV) from stable to worsening HF was estimated as follows: 100 × {Hb (stable) × [1 - Ht (worse)]}/{Hb (worse) × [1 - Ht (stable)]} - 100. When patients were divided into two groups based on changes in serum Cl concentration from stable to worsening HF, the pathophysiologic features of the patients with increased Cl (range 1-23 mEq/L; n = 31) included a greater increase in serum sodium (2.94 ± 4.15 vs. -0.69 ± 3.75 mEq/L, P = 0.005), higher vascular expansion (12 ± 11.1 vs. 4.81 ± 7.94%, P = 0.026), a tendency towards a greater MCV (1.23 ± 2.36 vs. -0.06 ± 1.88 fL, P = 0.065), and preserved renal function defined by the absence of an increase of serum creatinine (-0.24 ± 0.39 vs. -0.05 ± 0.12 mg/dL, P = 0.057) compared to patients with non-increased Cl (range -9 to 0 mEq/L; n = 16). Clinically, the increased Cl group had fewer HF signs (2.65 ± 0.71 vs. 3.31 ± 0.79, P = 0.005) although the change in symptoms did not differ between groups (48% vs. 63%, P = 0.54). CONCLUSIONS The present study suggests a new clinical entity of worsening HF status, that is, HF with increased vs. non-increased serum Cl concentration from clinical stability to worsening HF.
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Affiliation(s)
- Hajime Kataoka
- Division of Internal MedicineNishida HospitalSaiki cityOitaJapan
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