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Biancucci M, Barbiero R, Pennella B, Cannatà A, Ageno W, Tangianu F, Maresca AM, Dentali F, Bonaventura A. Hypoalbuminaemia and heart failure: A practical review of current evidence. Eur J Heart Fail 2024. [PMID: 38962822 DOI: 10.1002/ejhf.3363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 04/23/2024] [Accepted: 04/29/2024] [Indexed: 07/05/2024] Open
Abstract
Hypoalbuminaemia (serum albumin levels ≤3.5 g/dl) is associated with poor outcomes among patients with heart failure (HF). This narrative review includes original articles and reviews published over the past 20 years and retrieved from PubMed using the following search terms (or their combination): 'heart failure', 'hypoalbuminaemia', 'heart failure with reduced ejection fraction', 'heart failure with preserved ejection fraction', 'all-cause mortality', 'in-hospital mortality', 'hospitalization', 'prognosis'. The aims of this review are to provide an overview on the prevalence of hypoalbuminaemia in HF, its impact on clinical outcomes, and potential mechanisms that may suggest future therapeutic strategies. Hypoalbuminaemia is frequent in HF patients, especially among the elderly. However, data about the exact epidemiology of hypoalbuminaemia are scant due to different definitions, and prevalence is estimated between 5% and 70% across the whole spectrum of ejection fraction. Current evidence points to hypoalbuminaemia as a marker of poor outcomes in HF, irrespective of the ejection fraction, and in other cardiovascular diseases. Among patients who suffered from acute coronary syndrome, those with hypoalbuminaemia had an increased risk of new-onset HF and in-hospital mortality. Albumin, however, might also play a role in the natural history of such diseases due to its antioxidant, anti-inflammatory, and antithrombotic properties. Whether albumin supplementation or nutritional support in general would be beneficial in improving clinical outcomes in HF is not completely clear and should be evaluated in adequately designed studies.
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Affiliation(s)
- Marta Biancucci
- Department of Internal Medicine, Medical Center, S.C. Medicina Generale 1, Ospedale di Circolo and Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | - Riccardo Barbiero
- Internal Medicine Residency Program, School of Medicine, University of Insubria, Varese, Italy
| | - Benedetta Pennella
- Department of Internal Medicine, Medical Center, S.C. Medicina Generale 1, Ospedale di Circolo and Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | - Antonio Cannatà
- King's College London British Heart Foundation Centre of Excellence, School of Cardiovascular Medicine & Sciences, London, UK
- King's College Hospital NHS Foundation Trust, London, UK
| | - Walter Ageno
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Flavio Tangianu
- Department of Internal Medicine, Medical Center, S.C. Medicina Generale 1, Ospedale di Circolo and Fondazione Macchi, ASST Sette Laghi, Varese, Italy
| | | | - Francesco Dentali
- Department of Medicine and Surgery, University of Insubria, Varese, Italy
| | - Aldo Bonaventura
- Department of Internal Medicine, Medical Center, S.C. Medicina Generale 1, Ospedale di Circolo and Fondazione Macchi, ASST Sette Laghi, Varese, Italy
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Kazory A. Contemporary Decongestive Strategies in Acute Heart Failure. Semin Nephrol 2024:151512. [PMID: 38702211 DOI: 10.1016/j.semnephrol.2024.151512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/06/2024]
Abstract
Congestion is the primary driver of hospital admissions in patients with heart failure and the key determinant of their outcome. Although intravenous loop diuretics remain the predominant agents used in the setting of acute heart failure, the therapeutic response is known to be variable, with a significant subset of patients discharged from the hospital with residual hypervolemia. In this context, urinary sodium excretion has gained attention both as a marker of response to loop diuretics and as a marker of prognosis that may be a useful clinical tool to guide therapy. Several decongestive strategies have been explored to improve diuretic responsiveness and removal of excess fluid. Sequential nephron blockade through combination diuretic therapy is one of the most used methods to enhance natriuresis and counter diuretic resistance. In this article, I provide an overview of the contemporary decongestive approaches and discuss the clinical data on the use of add-on diuretic therapy. I also discuss mechanical removal of excess fluid through extracorporeal ultrafiltration with a brief review of the results of landmark studies. Finally, I provide a short overview of the strategies that are currently under investigation and may prove helpful in this setting.
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Affiliation(s)
- Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, College of Medicine, University of Florida, Gainesville, FL.
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Callum J, Skubas NJ, Bathla A, Keshavarz H, Clark EG, Rochwerg B, Fergusson D, Arbous S, Bauer SR, China L, Fung M, Jug R, Neill M, Paine C, Pavenski K, Shah PS, Robinson S, Shan H, Szczepiorkowski ZM, Thevenot T, Wu B, Stanworth S, Shehata N. Use of Intravenous Albumin: A Guideline From the International Collaboration for Transfusion Medicine Guidelines. Chest 2024:S0012-3692(24)00285-X. [PMID: 38447639 DOI: 10.1016/j.chest.2024.02.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 02/23/2024] [Accepted: 02/27/2024] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Albumin is used commonly across a wide range of clinical settings to improve hemodynamics, to facilitate fluid removal, and to manage complications of cirrhosis. The International Collaboration for Transfusion Medicine Guidelines developed guidelines for the use of albumin in patients requiring critical care, undergoing cardiovascular surgery, undergoing kidney replacement therapy, or experiencing complications of cirrhosis. METHODS Cochairs oversaw the guideline development process and the panel included researchers, clinicians, methodologists, and a patient representative. The evidence informing this guideline arises from a systematic review of randomized clinical trials and systematic reviews, in which multiple databases were searched (inception through November 23, 2022). The panel reviewed the data and formulated the guideline recommendations using Grading of Recommendations Assessment, Development and Evaluation methodology. The guidelines were revised after public consultation. RESULTS The panel made 14 recommendations on albumin use in adult critical care (three recommendations), pediatric critical care (one recommendation), neonatal critical care (two recommendations), cardiovascular surgery (two recommendations), kidney replacement therapy (one recommendation), and complications of cirrhosis (five recommendations). Of the 14 recommendations, two recommendations had moderate certainty of evidence, five recommendations had low certainty of evidence, and seven recommendations had very low certainty of evidence. Two of the 14 recommendations suggested conditional use of albumin for patients with cirrhosis undergoing large-volume paracentesis or with spontaneous bacterial peritonitis. Twelve of 14 recommendations did not suggest albumin use in a wide variety of clinical situations where albumin commonly is transfused. CONCLUSIONS Currently, few evidence-based indications support the routine use of albumin in clinical practice to improve patient outcomes. These guidelines provide clinicians with actionable recommendations on the use of albumin.
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Affiliation(s)
- Jeannie Callum
- Department of Pathology and Molecular Medicine, Queen's University and Kingston Health Sciences Centre, Kingston.
| | - Nikolaos J Skubas
- Department of Cardiothoracic Anesthesiology, Anesthesiology Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland
| | | | | | - Edward G Clark
- Division of Nephrology, University of Ottawa, Ottawa Hospital Research Institute, Ottawa
| | - Bram Rochwerg
- Department of Medicine and Department of Health Research Methods, Evidence and Impact, Faculty of Health Sciences, McMaster University, Hamilton
| | - Dean Fergusson
- Department of Medicine, University of Ottawa, Ottawa Hospital Research Institute, Ottawa
| | - Sesmu Arbous
- Department of Critical Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Seth R Bauer
- Department of Pharmacy, Cleveland Clinic, Cleveland
| | - Louise China
- Department of Hepatology and ILDH, The Royal Free NHS Trust and University College London, London
| | - Mark Fung
- Department of Pathology and Laboratory Medicine, University of Vermont Medical Center, Burlington, VT
| | - Rachel Jug
- University of Cincinnati College of Medicine, Cincinnati, OH
| | | | - Cary Paine
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA
| | - Katerina Pavenski
- Department of Laboratory Medicine and Pathobiology, Mount Sinai Hospital, Toronto, ON
| | - Prakesh S Shah
- Institute of Health Policy, Management, and Evaluation, Mount Sinai Hospital, Toronto, ON; Department of Pediatrics, Mount Sinai Hospital, Toronto, ON
| | - Susan Robinson
- Department of Clinical Haematology, Guy's and St Thomas' NHS Foundation Trust, London
| | - Hua Shan
- Department of Pathology, Stanford University School of Medicine, Palo Alto
| | | | - Thierry Thevenot
- Service d'Hépatologie, Centre Hospitalier Régional et Universitaire de Besançon, Besançon, France
| | - Bovey Wu
- Department of Internal Medicine, Graduate Medical Education, Loma Linda University, Loma Linda, CA
| | - Simon Stanworth
- NHS Blood and Transplant, Oxford, England; Radcliffe Department of Medicine, University of Oxford, Oxford, England; John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, England
| | - Nadine Shehata
- Department of Medicine, University of Toronto, Mount Sinai Hospital, Toronto, ON; Transfusion Medicine Laboratory, Mount Sinai Hospital, Toronto, ON
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Vipler BS, Barelski AM, Vipler EE. Things We Do for No Reason™: Furosemide-albumin coadministration for diuretic resistance. J Hosp Med 2024. [PMID: 38372456 DOI: 10.1002/jhm.13297] [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: 06/05/2023] [Revised: 10/03/2023] [Accepted: 01/28/2024] [Indexed: 02/20/2024]
Affiliation(s)
- Benjamin S Vipler
- Division of Hospital Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Adam M Barelski
- Division of Cardiovascular Diseases, The University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Erin E Vipler
- Division of Palliative Care, University of Colorado School of Medicine, Aurora, Colorado, USA
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5
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Fernandez Hazim C, Duarte G, Urena AP, Jain S, Mishra R, Vittorio TJ, Rodriguez-Guerra M. Diuretic resistance and the role of albumin in congestive heart failure. Drugs Context 2023; 12:2023-6-5. [PMID: 38188263 PMCID: PMC10768781 DOI: 10.7573/dic.2023-6-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 11/20/2023] [Indexed: 01/09/2024] Open
Abstract
Diuresis with loop diuretics is the mainstay treatment for volume optimization in patients with congestive heart failure, in which perfusion and volume expansion play a crucial role. There are robust guidelines with extensive evidence for the management of heart failure; however, clear guidance is needed for patients who do not respond to standard diuretic treatment. Diuretic resistance (DR) can be defined as an insufficient quantity of natriuresis with proper diuretic therapy. A combination of diuretic regimens is used to overcome DR and, more recently, SGLT2 inhibitors have been shown to improve diuresis. Despite DR being relatively common, it is challenging to treat and there remains a notable lack of substantial data guiding its management. Moreover, DR has been linked with poor prognosis. This review aims to expose the multiple approaches for treatment of patients with DR and the importance of intravascular volume expansion in the response to therapy.
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Affiliation(s)
| | | | - Ana P Urena
- Medicina Cardiovascular Asociada, Santo Domingo, Dominican Republic
| | - Swati Jain
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Rishabh Mishra
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Timothy J Vittorio
- BronxCare Health System, Icahn School of Medicine at Mt. Sinai, Bronx, NY, USA
| | - Miguel Rodriguez-Guerra
- Department of Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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6
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Lindner ML, Lohmeyer JL, Adam EH, Zacharowski K, Weber CF. [Mechanisms of action and clinical application of diuretics in intensive care medicine]. DIE ANAESTHESIOLOGIE 2023; 72:757-770. [PMID: 37768358 DOI: 10.1007/s00101-023-01338-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 09/29/2023]
Abstract
The paired kidneys play a significant role in the human body due to the multitude of physiological tasks. Complex biochemical processes keep the sensitive electrolyte and water balance stable and thus ensure the organism's ability to adapt to exogenous and endogenous factors, which is essential for survival. The drug class of diuretics includes substances with very differing pharmacological characteristics. The functioning of the nephron is therefore indispensable for a deeper understanding of the pharmacodynamics, pharmacokinetics and side effect profile of diuretics. In the treatment of acute heart failure with pulmonary congestion, certain diuretics represent an important therapeutic option to counteract hypervolemia and thus an increase in preload. According to current data, diuretics have no proven benefits in the treatment or prevention of acute kidney injury but they can counteract hypervolemia and under certain conditions even reduce the use of renal replacement procedures.
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Affiliation(s)
- M-L Lindner
- Abteilung für Anästhesiologie, Intensiv- und Notfallmedizin, Asklepios Kliniken Hamburg GmbH, Asklepios Klinik Wandsbek, Alphonsstraße 14, 22043, Hamburg, Deutschland.
| | - J L Lohmeyer
- Abteilung für Anästhesiologie, Intensiv‑, Notfall-, und Schmerzmedizin, Asklepios Kliniken Hamburg GmbH, Asklepios Klinik Altona, Paul-Ehrlich-Straße 1, 22763, Hamburg, Deutschland
| | - E H Adam
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor Stern Kai 7, 60590, Frankfurt, Deutschland
| | - K Zacharowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor Stern Kai 7, 60590, Frankfurt, Deutschland
| | - C F Weber
- Abteilung für Anästhesiologie, Intensiv- und Notfallmedizin, Asklepios Kliniken Hamburg GmbH, Asklepios Klinik Wandsbek, Alphonsstraße 14, 22043, Hamburg, Deutschland
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Goethe-Universität, Theodor Stern Kai 7, 60590, Frankfurt, Deutschland
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7
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Koirala A, Pourafshar N, Daneshmand A, Wilcox CS, Mannemuddhu SS, Arora N. Etiology and Management of Edema: A Review. ADVANCES IN KIDNEY DISEASE AND HEALTH 2023; 30:110-123. [PMID: 36868727 DOI: 10.1053/j.akdh.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 04/18/2023]
Abstract
The development of peripheral edema can often pose a significant diagnostic and therapeutic challenge for practitioners due to its association with a wide variety of underlying disorders ranging in severity. Updates to the original Starling's principle have provided new mechanistic insights into edema formation. Additionally, contemporary data highlighting the role of hypochloremia in the development of diuretic resistance provide a possible new therapeutic target. This article reviews the pathophysiology of edema formation and discusses implications for treatment.
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Affiliation(s)
- Abbal Koirala
- Division of Nephrology, University of Washington, Seattle, WA
| | - Negiin Pourafshar
- Division of Nephrology, MedStar Georgetown University Hospital, Washington DC
| | - Arvin Daneshmand
- Division of Nephrology, MedStar Georgetown University Hospital, Washington DC
| | | | | | - Nayan Arora
- Division of Nephrology, University of Washington, Seattle, WA.
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8
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Fernandes J, Costa R, Guerreiro R, Bonifácio D, Rodrigues A, Henriques C, Branco P, Araújo I, Fonseca C. Co-Administration of Albumin and Furosemide in Acute Heart Failure with Diuretics Resistance. ACTA MEDICA PORT 2023; 36:193-201. [PMID: 36762993 DOI: 10.20344/amp.17714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 10/11/2022] [Indexed: 02/11/2023]
Abstract
Acute heart failure is a frequent cause of hospital admission in Portugal, and has an increasing tendency given the aging population. Although most admissions for acute heart failure are caused by congestive conditions, not all patients have a congestive phenotype, reflecting the complexity of a process with multiple pathophysiological pathways. The use of diuretics, usually loop diuretics, is the mainstay of treatment for congestion. However, many patients develop resistance, thus constituting a challenge with no consensual solution to date, despite extensive debate over the years. Despite its frequent use in clinical practice, the co-administration of albumin and furosemide remains controversial in the management of patients with acute heart failure, hypoalbuminemia, and diuretic resistance. This review addresses the pathophysiological mechanisms of congestion in patients with acute heart failure and explores the theoretical basis that supports the co-administration of albumin and furosemide in this clinical context. It is intended to clarify the potential benefit of the combined approach in this specific population and identify possible gaps in the literature that could be the subject of future studies.
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Affiliation(s)
- Jorge Fernandes
- Unidade Funcional de Medicina Interna 7.2. Hospital Curry Cabral. Centro Hospitalar Universitário de Lisboa Central. Lisboa. Portugal
| | - Rita Costa
- Serviço de Medicina Interna. Centro Hospitalar de Vila Nova de Gaia/Espinho. Vila Nova de Gaia..
| | - Renato Guerreiro
- Serviço de Medicina Interna. Hospital de São Francisco Xavier. Centro Hospitalar de Lisboa Ocidental. Lisboa. Portugal
| | - Dulce Bonifácio
- Serviço de Medicina Interna. Hospital Distrital de Torres Vedras. Centro Hospitalar do Oeste. Torres Vedras. Portugal
| | - Ana Rodrigues
- Serviço de Medicina Interna. Unidade Local de Saúde do Norte Alentejano. Hospital Santa Luzia de Elvas. Elvas. Portugal
| | - Célia Henriques
- Clínica de Insuficiência Cardíaca. Serviço de Medicina III. Hospital de São Francisco Xavier. Centro Hospitalar de Lisboa Ocidental. Lisboa; NOVA Medical School. Faculdade de Ciências Médicas. Universidade Nova de Lisboa. Lisboa. Portugal
| | - Patrícia Branco
- NOVA Medical School. Faculdade de Ciências Médicas. Universidade Nova de Lisboa. Lisboa; Serviço de Nefrologia. Hospital de Santa Cruz. Centro Hospitalar de Lisboa Ocidental. Lisboa. Portugalm
| | - Inês Araújo
- Clínica de Insuficiência Cardíaca. Serviço de Medicina III. Hospital de São Francisco Xavier. Centro Hospitalar de Lisboa Ocidental. Lisboa; NOVA Medical School. Faculdade de Ciências Médicas. Universidade Nova de Lisboa. Lisboa. Portugal
| | - Cândida Fonseca
- Clínica de Insuficiência Cardíaca. Serviço de Medicina III. Hospital de São Francisco Xavier. Centro Hospitalar de Lisboa Ocidental. Lisboa; NOVA Medical School. Faculdade de Ciências Médicas. Universidade Nova de Lisboa. Lisboa. Portugal
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9
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Christina NM, Tjahyanto T, Lie JG, Santoso TA, Albertus H, Octavianus D, Putri DAUI, Andrew J, Jatinugroho YD, Shiady C, Wijaya JH. Hypoalbuminemia and colorectal cancer patients: Any correlation?: A systematic review and meta-analysis. Medicine (Baltimore) 2023; 102:e32938. [PMID: 36827017 PMCID: PMC10162791 DOI: 10.1097/md.0000000000032938] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 01/23/2023] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND In malnourished patients with colorectal cancer, hypoalbuminemia is common and was proposed to determine the postoperative outcome of colorectal surgery. Mounting articles published but have not been evaluated. We aim to assess the predictive value of preoperative hypoalbuminemia in patients undergoing colorectal surgery. METHODS We performed a literature search from PubMed, Euro PMC, and Cochrane with the terms serum albumin, hypoalbuminemia, prognosis, outcome, colorectal cancer, and neoplasm. We also hand-searched and included any relevant papers. Hypoalbuminemia is defined as plasma albumin level < 3.5 mg/dL. We restricted the included studies to English language and adults undergoing colectomy, laparotomy, laparoscopy, or abdominoperineal resection. Any types of articles were included, except an abstract-only publication and those that did not report the key exposure or outcome of interest. The key exposures were mortality, hospitalization time, and morbid conditions (thrombosis, surgical site infection, sepsis, and wound events). We pooled the odds ratio from each included literature as effect size. The Newcastle Ottawa scale and GRADE were used to determine the quality of each included study. RESULTS Hereof 7 observational studies (236,480 individuals) were included. Our meta-analysis found that preoperative hypoalbuminemia can predict the postoperative outcome in colorectal cancer patients. Individuals with hypoalbuminemia were not associated with 30-day mortality (risk ratio [RR] 2.05 [0.72, 5.86], P = .18, I2 = 99%) but were associated with morbidity (RR 2.28 [1.78, 2.93], P < .00001, I2 = 87.5%), surgical complication (RR 1.69 [1.34, 2.13], P < .00001, I2 = 98%), and hospitalization (RR 2.21 [1.93, 2.52], P < .00001, I2 = 0%). According to newcastle ottawa scale, the included studies are of moderate to sound quality. CONCLUSIONS The current systematic review and meta-analysis showed that preoperative hypoalbuminemia was significantly associated with morbidity, length of stay, and surgical complication but not mortality.
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Affiliation(s)
| | - Teddy Tjahyanto
- Department of Medicine, Universitas Tarumanagara, Jakarta, Indonesia
| | - Jason Gunawan Lie
- Department of Medicine, Universitas Tarumanagara, Jakarta, Indonesia
| | | | - Hans Albertus
- Department of Surgery, Universitas Pelita Harapan, Tangerang, Banten, Indonesia
| | - Daniel Octavianus
- Department of Medicine, Universitas Tarumanagara, Jakarta, Indonesia
| | | | - Johanes Andrew
- Department of Medicine, Universitas Tarumanagara, Jakarta, Indonesia
| | | | - Christian Shiady
- Department of Medicine, Universitas Tarumanagara, Jakarta, Indonesia
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Reis T, Ronco F, Ostermann M. Diuretics and Ultrafiltration in Heart Failure. Cardiorenal Med 2023; 13:56-65. [PMID: 36630939 DOI: 10.1159/000529068] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/15/2022] [Indexed: 01/12/2023] Open
Abstract
Fluid overload is a risk factor for increased morbidity and mortality, especially in patients with heart disease. The treatment options are limited to diuretics and mechanical fluid removal using ultrafiltration or renal replacement therapy. This paper provides an overview of the challenges of managing fluid overload, outlines the risks and benefits of different pharmacological options and extracorporeal techniques, and provides guidance for clinical practice.
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Affiliation(s)
- Thiago Reis
- Division of Kidney Transplantation, D'Or Institute for Research and Education (IDOR), DF Star Hospital, Brasília, Brazil
- Laboratory of Molecular Pharmacology, Faculty of Health Sciences, University of Brasília, Asa Norte, Campus Darcy Ribeiro, Brasília, Brazil
| | - Federico Ronco
- Interventional Cardiology, Ospedale dell'Angelo, Mestre, Venezia, Italy
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St Thomas' Hospital, London, UK
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11
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Huang H, Hu C, Fu Y, Han Z, Cao M, Fu G. THE EFFECTS OF EARLY-PHASE FUROSEMIDE USE ON THE PROGRESSION OF OLIGURIC ACUTE KIDNEY INJURY ACROSS DIFFERENT CENTRAL VENOUS PRESSURE: A RETROSPECTIVE ANALYSIS. Shock 2023; 59:49-57. [PMID: 36377392 DOI: 10.1097/shk.0000000000002045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
ABSTRACT Background: Furosemide is a commonly used loop diuretic in critical care. However, its effect on the progression of oliguric acute kidney injury across different central venous pressure (CVP) remains unknown. This study therefore aims to investigate the association between furosemide 6-12h (defined as the use of furosemide within 6 h after the diagnosis of AKI according to the urine output [UO] criteria set by the Kidney Disease: Improving Global Outcomes [KDIGO] guidelines) and the progression of AKI across different CVP 6-12h (defined as CVP within 6 h after the diagnosis of AKI by the KDIGO UO criteria) levels. Methods: Patients involved in this study were identified from the Medical Information Mart for Intensive Care IV database with the following criteria: (i) adults with UO <0.5 mL/kg per hour for the first 6 h upon admission to the intensive care unit (ICU) (meeting stage 1 AKI by UO) and (ii) CVP 6-12h ranging from 0 to 30 mm Hg. From there on, the target primary outcome would be progression to stage 3 AKI by UO among these chosen patients. The secondary outcome was 28-d mortality since ICU admission. The risks of severe-stage AKI progression and 28-d mortality were respectively examined against furosemide 6-12h (vs. without furosemide 6-12h ) within the full cohort and across different subgroups of CVP 6-12h , using multivariate adjusted logistic regression and inverse probability treatment weighting (IPTW). Sensitivity analyses were performed to assess the robustness of our findings. Results: One thousand one hundred eighty patients were ultimately selected for this study, of whom 643 (54.5%) progressed to stage 3 AKI from stage 1 based on the UO criteria by KDIGO. Multivariate analysis showed that furosemide 6-12h is significantly associated with this severe-stage progression within the full cohort (odds ratio [OR] was 0.62 at 95% confidence interval [CI] of 0.43-0.90, P = 0.011). After dividing the patients into CVP 6-12h subgroups according to their CVP during the early phases, lower risk of AKI progression was observed only in furosemide 6-12h application at CVP 6-12h of ≥12 mm Hg (adjusted OR was 0.40 at 95% CI of 0.25-0.65, P < 0.001), as confirmed by the IPTW analysis (OR was 0.47 at 95% CI of 0.29-0.76, P = 0.002). The robustness of these findings was confirmed by sensitivity analyses. In addition, for patients with CVP 6-12h ≥12 mm Hg, furosemide 6-12h is also significantly associated with lower risk of 28-d mortality (adjusted OR was 0.47 at 95% CI of 0.25-0.92, P = 0.026) in the multivariate logistic regression analysis, and there was a similar trend in the IPTW analysis (adjusted OR was 0.55 at 95% CI of 0.28-1.10, P = 0.092). Conclusions: Among the identified early-stage AKI patients in critical care, the use of furosemide was associated only with lower risk of oliguric AKI progression and 28-d mortality within the high CVP group. These findings suggest the potential of CVP as a guidance or reference point in the usage of furosemide among early-stage oliguric AKI patients in the ICU.
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Affiliation(s)
- Haoquan Huang
- Department of Anesthesiology, Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, China
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12
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Impact of Albumin Binding Function on Pharmacokinetics and Pharmacodynamics of Furosemide. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121780. [PMID: 36556982 PMCID: PMC9787406 DOI: 10.3390/medicina58121780] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/26/2022] [Accepted: 12/01/2022] [Indexed: 12/12/2022]
Abstract
Background and Objectives: Albumin binding of the loop diuretic furosemide forms the basis for its transport to the kidney and subsequent tubular secretion, which is a prerequisite for its therapeutic effects. Accordingly, high albumin concentrations should result in higher efficacy of furosemide. However, study results on the combination of furosemide in conjunction with albumin, and on the efficacy of furosemide in hypoalbuminemia, did not confirm this hypothesis. The aim of this study was to determine the efficacy of furosemide not only in relation to albumin concentration, but also taking albumin function into account. Materials and Methods: In a prospective and non-interventional clinical observational trial, blood and urine samples from 50 intensive care patients receiving continuous intravenous furosemide therapy were evaluated. Albumin binding capacity (ABiC) determination allowed conclusions to be drawn about the binding site-specific loading state of albumin, by quantifying the unbound fraction of the fluorescent marker dansylsarcosine. In addition, assessment of the total concentration of furosemide in plasma and urine, as well as the concentration of free furosemide fraction in plasma, was performed by HPLC−MS. The efficacy of furosemide was evaluated by the ratio of urine excretion to fluid intake. Results: In patients with an ABiC ≥ 60% free furosemide fraction was significantly lower compared to patients with a lower ABiC (p < 0.001), urinary furosemide concentration was higher (p = 0.136), and a significantly higher proportion of infused furosemide was excreted renally (p = 0.010). ABiC was positively correlated (r = 0.908, p = 0.017) with increase in the urine excretion to fluid input ratio after initiation of furosemide therapy. Conclusions: ABiC could serve as a marker for individual response to furosemide and could be used to generate patient-specific therapeutic regimens. In view of the relatively low number of patients in this study, the relationship between furosemide efficacy and albumin function should be investigated in larger studies in the future.
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13
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Hedin E, Bijelić V, Barrowman N, Geier P. Furosemide and albumin for the treatment of nephrotic edema: a systematic review. Pediatr Nephrol 2022; 37:1747-1757. [PMID: 35239032 DOI: 10.1007/s00467-021-05358-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 11/07/2021] [Accepted: 11/08/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Edema is one of the cardinal clinical features of nephrotic syndrome (NS). It may vary from mild periorbital edema to severe generalized edema (anasarca). In patients where edema does not improve with prednisone therapy, the most common supportive medications are diuretics and albumin. However, due to the complex pathophysiology of edema formation in NS patients resulting in intravascular normovolemia or hypovolemia, optimal therapy for edema is still debated. We conducted a systematic review with the objective of evaluating the change in urine volume and urine sodium excretion after treatment with furosemide only versus furosemide with albumin in edematous patients with NS. OBJECTIVES (1) To evaluate efficacy of furosemide alone versus furosemide with albumin in the treatment of nephrotic edema in adults and children. (2) To compare the harms and benefits of different doses of furosemide for treating nephrotic edema. SEARCH METHODS The search included all randomized or quasi-randomized controlled trials in English and French using MEDLINE, Embase, and CENTRAL Trials Registry of the Cochrane Collaboration using the Ovid interface. CLINICALTRIALS gov and the International Clinical Trials Registry Platform were also searched. SELECTION CRITERIA We included all RCTs and randomized cross-over studies in which furosemide and furosemide plus albumin are used in the treatment of children or adults with nephrotic edema. We excluded patients with hypoalbuminemia of non-renal origin and severe chronic kidney disease (CKD) with a glomerular filtration rate below 30 ml/min/1.74 m2 and patients with congenital NS. DATA COLLECTION AND ANALYSIS All abstracts were independently assessed by at least two authors to determine which studies met the inclusion criteria. Information on study design, methodology, and outcome data (urine volume, urine sodium excretion, adverse effects) from each identified study was entered into a separate data sheet. The differences in outcomes between the types of therapy were expressed as standardized mean difference (SMD) with 95% confidence intervals (CI). RESULTS The search yielded 525 records, and after screening, five studies were included in the systematic review and four of those studies in the meta-analysis. One study had high risk of bias and the remaining three studies were deemed to have some concerns. Urine excretion was greater after treatment with furosemide and albumin versus furosemide (SMD 0.85, 95% CI = 0.33 to 1.38). Results for sodium excretion were inconclusive (SMD 0.37, 95%CI = - 0.28 to 1.02). AUTHORS' CONCLUSIONS The current evidence is not sufficient to make definitive conclusions about the role of albumin in treating nephrotic edema. High-quality randomized studies with adequate samples sizes are needed. Including an assessment of intravascular volume status may be helpful. TRIAL REGISTRATION Prospero: CRD4201808979. https://www.crd.york.ac.uk/PROSPERO A higher resolution version of the Graphical abstract is available as Supplementary information.
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Affiliation(s)
- Erin Hedin
- Department of Pediatrics, Stollery Children's Hospital, University of Alberta, 8440 112 St NW, Edmonton, AB, T6G2B7, Canada.
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada.
| | - Vid Bijelić
- CHEO Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Nick Barrowman
- CHEO Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Pavel Geier
- Department of Pediatrics, Children's Hospital of Eastern Ontario, University of Ottawa, Ottawa, ON, Canada
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Civera J, Miñana G, de la Espriella R, Santas E, Sastre C, Mollar A, Conesa A, Martínez A, Núñez E, Bayés-Genís A, Núñez J. Venous Leg Compression for Tissue Decongestion in Patients With Worsening Congestive Heart Failure. Front Cardiovasc Med 2022; 9:847450. [PMID: 35872894 PMCID: PMC9304621 DOI: 10.3389/fcvm.2022.847450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
AimsVenous leg compression (VLC) with elastic bandages has been proposed as a potentially useful strategy for decreasing tissue congestion. We aimed to evaluate the effect of VLC on short-term changes on intravascular refill, assessed by inferior vena cava (IVC) diameter in patients with worsening heart failure (WHF) requiring parenteral furosemide. Additionally, we sought to evaluate whether early changes in IVC were related to short-term decongestion.MethodsThis is a prospective study in which we included 20 consecutive ambulatory patients with WHF treated with subcutaneous furosemide and VLC for at least 72 h. The endpoints were (a) short-term changes in IVC, (b) the association between decongestion and 3-h IVC changes following VLC. Changes in continuous endpoints and their longitudinal trajectories were estimated with linear mixed regression models. All analyses were adjusted for multiple comparisons.ResultsFollowing administration of subcutaneous furosemide and VLC, we found a significant increase in 3-h IVC diameter (ΔIVC = 1.6 mm, CI 95%: 0.7–2.5; p < 0.001), with a greater increase in those with baseline IVC≤21 mm (2.4 vs. 0.8 mm; p < 0.001). 3-h intravascular refill (increase in IVC≥2 mm) was associated with greater decongestion (natriuresis, weight, peripheral edemas, and dyspnea) in those with baseline IVC≤21 mm but not when IVC>21 mm (p < 0.05 for all comparisons).ConclusionsIn this cohort of patients with congestive WHF treated with subcutaneous furosemide and VLC, we found a greater increase in short-term IVC in those with IVC ≤21 mm at baseline. In this subset of patients, a 3-h increase in IVC≥2 mm was associated with greater short-term decongestion.
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Affiliation(s)
- Jose Civera
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Gema Miñana
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
- CIBER in Cardiovascular Diseases (CIBERCV), Madrid, Spain
| | - Rafael de la Espriella
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Enrique Santas
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Clara Sastre
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Anna Mollar
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Adriana Conesa
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Ana Martínez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Eduardo Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
| | - Antoni Bayés-Genís
- CIBER in Cardiovascular Diseases (CIBERCV), Madrid, Spain
- Heart Failure Unit, Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
- Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario de Valencia, INCLIVA Instituto de Investigación Sanitaria, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
- CIBER in Cardiovascular Diseases (CIBERCV), Madrid, Spain
- *Correspondence: Julio Núñez ; ; orcid.org/0000-0003-1672-7119
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Abstract
The introduction of multiple new pharmacological agents over the past three decades in the field of heart failure with reduced ejection fraction (HFrEF) has led to reduced rates of mortality and hospitalizations, and consequently the prevalence of HFrEF has increased, and up to 10% of patients progress to more advanced stages, characterized by high rates of mortality, hospitalizations, and poor quality of life. Advanced HFrEF patients often show persistent or progressive signs of severe HF symptoms corresponding to New York Heart Association class III or IV despite being on optimal medical, surgical, and device therapies. However, a subpopulation of patients with advanced HF, those with the most advanced stages of disease, were often insufficiently represented in the major trials demonstrating efficacy and tolerability of the drugs used in HFrEF due to exclusion criteria such as low BP and kidney dysfunction. Consequently, the results of many landmark trials cannot necessarily be transferred to patients with the most advanced stages of HFrEF. Thus, the efficacy and tolerability of guideline-directed medical therapies in patients with the most advanced stages of HFrEF often remain unsettled, and this knowledge is of crucial importance in the planning and timing of consideration for referral for advanced therapies. This review discusses the evidence regarding the use of contemporary drugs in the advanced HFrEF population, covering components such as guideline HFrEF drugs, diuretics, inotropes, and the use of HFrEF drugs in LVAD recipients, and provides suggestions on how to manage guideline-directed therapy in this patient group.
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16
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Lee TH, Kuo G, Chang CH, Huang YT, Yen CL, Lee CC, Fan PC, Chen JJ. Diuretic effect of co-administration of furosemide and albumin in comparison to furosemide therapy alone: An updated systematic review and meta-analysis. PLoS One 2021; 16:e0260312. [PMID: 34851962 PMCID: PMC8635380 DOI: 10.1371/journal.pone.0260312] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND It has been a matter of much debate whether the co-administration of furosemide and albumin can achieve better diuresis and natriuresis than furosemide treatment alone. There is inconsistency in published trials regarding the effect of this combination therapy. We, therefore, conducted this meta-analysis to explore the efficacy of furosemide and albumin co-administration and the factors potentially influencing the diuretic effect of such co-administration. METHODS In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched the PubMed, Embase, Medline, and Cochrane databases. Prospective studies with adult populations which comparing the effect of furosemide and albumin co-administration with furosemide alone were included. The outcomes including diuretic effect and natriuresis effect measured by hourly urine output and hourly urine sodium excretion from both groups were extracted. Random effect model was applied for conducting meta-analysis. Subgroup analysis and sensitivity analysis were performed to explore potential sources of heterogeneity of treatment effects. RESULTS By including 13 studies with 422 participants, the meta-analysis revealed that furosemide with albumin co-administration increased urine output by 31.45 ml/hour and increased urine excretion by 1.76 mEq/hour in comparison to furosemide treatment alone. The diuretic effect of albumin and furosemide co-administration was better in participants with low baseline serum albumin levels (< 2.5 g/dL) and high prescribed albumin infusion doses (> 30 g), and the effect was more significant within 12 hours after administration. Diuretic effect of co-administration was better in those with baseline Cr > 1.2 mg/dL and natriuresis effect of co-administration was better in those with baseline eGFR < 60 ml/min/1.73m2. CONCLUSION Co-administration of furosemide with albumin might enhance diuresis and natriuresis effects than furosemide treatment alone but with high heterogeneity in treatment response. According to the present meta-analysis, combination therapy might provide advantages compared to the furosemide therapy alone in patients with baseline albumin levels lower than 2.5 g/dL or in patients receiving higher albumin infusion doses or in patients with impaired renal function. Owing to high heterogeneity and limited enrolled participants, further parallel randomized controlled trials are warranted to examine our outcome. REGISTRATION PROSEPRO ID: CRD42020211002; https://clinicaltrials.gov/.
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Affiliation(s)
- Tao Han Lee
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - George Kuo
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
- * E-mail: (GK); (J-JC)
| | - Chih-Hsiang Chang
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Yen Ta Huang
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Chieh Li Yen
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Pei Chun Fan
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Graduate Institute of Clinical Medical Science, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Jia-Jin Chen
- Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- * E-mail: (GK); (J-JC)
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17
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Inpatient Diuretic Management of Acute Heart Failure: A Practical Review. Am J Cardiovasc Drugs 2021; 21:595-608. [PMID: 33709346 DOI: 10.1007/s40256-020-00463-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 02/08/2023]
Abstract
The inpatient treatment of acute heart failure (AHF) is aimed at achieving euvolemia, relieving symptoms, and reducing rehospitalization. Adequate treatment of AHF is rooted in understanding the pharmacokinetics and pharmacodynamics of select diuretic agents used to achieve decongestion. While loop diuretics remain the primary treatment of AHF, the dosing strategies of loop diuretics and the use of adjunct diuretic classes to augment clinical response can be complex. This review examines the latest strategies for diuretic management in patients with AHF, including dosing and monitoring strategies, interaction of diuretics with other medication classes, use adjunctive therapies, and assessing endpoints for diuretic. The goal of the review is to guide the reader through commonly encountered clinical scenarios and pitfalls in the diuretic management of patients with AHF.
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18
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Mayerhöfer T, Wiedermann CJ, Joannidis M. [Use of albumin : State of the art]. Med Klin Intensivmed Notfmed 2021; 116:655-664. [PMID: 34618163 PMCID: PMC8496431 DOI: 10.1007/s00063-021-00875-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 08/19/2021] [Accepted: 09/06/2021] [Indexed: 01/01/2023]
Abstract
The Saline versus Albumin Fluid Evaluation (SAFE) study has demonstrated that the use of albumin as an infusion solution in volume therapy can be regarded as safe. An exception is hypo-oncotic albumin in traumatic brain injury. While clear indications of albumin exist for some patients with liver cirrhosis, large studies that demonstrate a clinically relevant advantage beyond hemodynamic effects and would therefore justify wider use in many other areas are still lacking. In large-volume paracentesis, spontaneous bacterial peritonitis, but also in hepatorenal syndrome, use of albumin is recommended and established due to clinical benefit in randomized controlled trials. In septic shock, use of albumin may be considered, with two large studies addressing this issue in Germany and Italy being still in the recruitment phase. For volume therapy, albumin can be used primarily when other measures for hemodynamic stabilization have been exhausted. This applies to volume resuscitation in hypovolemia as well as in conservative fluid management in the so-called "de-resuscitation" phase. The extent to which the correction of severe hypoalbuminemia with exogenous albumin can improve the impaired outcome of these patients is also part of ongoing studies. On the way to a more individualized medicine, hypoalbuminemia may serve as a parameter in future decision making for or against the use of albumin in volume therapy.
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Affiliation(s)
- Timo Mayerhöfer
- Gemeinsame Einrichtung für Intensiv- und Notfallmedizin, Abteilung für Innere Medizin I, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - Christian J Wiedermann
- Institut für Public Health, Medical Decision Making und HTA, UMIT Private Universität für Gesundheitswissenschaften, Medizinische Informatik und Technik, Hall in Tirol, Österreich.,Institut für Allgemeinmedizin, Landesfachhochschule für Gesundheitsberufe Claudiana, Bozen, Italien
| | - Michael Joannidis
- Gemeinsame Einrichtung für Intensiv- und Notfallmedizin, Abteilung für Innere Medizin I, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
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19
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Schley G, Willam C. ["Intravascular space contracted-tissue space expanded": interstitial edema and fluid management in intensive care medicine]. Med Klin Intensivmed Notfmed 2021; 116:665-671. [PMID: 34605939 DOI: 10.1007/s00063-021-00872-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
In the second phase of shock therapy, we regularly find fluid overload with edema in our patients, which not only involves the skin and interstitial tissue but can also impair kidney, liver and pulmonary function. Revision of the Starling principle and new insights into physiology of the endothelial glycocalyx have important implications for fluid therapy in intensive care medicine. Determination of fluid overload and an appropriate therapy with either diuretics or ultrafiltration are the focus of "late goal-directed fluid removal" management.
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Affiliation(s)
- Gunnar Schley
- Medizinische Klinik 4, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
| | - Carsten Willam
- Medizinische Klinik 4, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
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20
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Côté JM, Bouchard J, Murray PT, Beaubien-Souligny W. Diuretic strategies in patients with resistance to loop-diuretics in the intensive care unit: A retrospective study from the MIMIC-III database. J Crit Care 2021; 65:282-291. [PMID: 34298494 DOI: 10.1016/j.jcrc.2021.06.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/14/2021] [Accepted: 06/15/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE To investigate various diuretic strategies to alleviate loop-diuretics resistance in critically ill patients. MATERIALS AND METHOD ICU adults requiring more than 1 mg/kg/day of furosemide, from the MIMIC-III database. Four diuretic strategies were investigated: incremental dose of loop diuretics, continuous infusion, combinations with a second class of diuretics and administration of intravenous albumin. A generalized estimating equation was used to investigate the associations between these strategies and endpoints. The primary outcome was the 24-h urine output and secondary endpoints included fluid balance, weight change, electrolyte and acid-base abnormalities, kidney replacement therapy initiation, and mortality. RESULTS A total of 7645 ICU stays from 6358 patients were included. After adjustment, the use of continuous loop-diuretic infusion was associated with a higher 24-h urine output (β: 732, 95% CI:669-795, p < 0.001), lower 24-h fluid balance (p < 0.001) and greater weight loss at 48-h (p < 0.001). Thiazide- and carbonic anhydrase inhibitor combinations were both associated with higher urine output (p < 0.001) and weight loss at 48-h (p < 0.01), while intravenous albumin was associated with fluid gain (p < 0.001). Risks of electrolyte and metabolic disturbances varied across diuretic strategies. CONCLUSIONS Continuous loop-diuretic infusion and thiazide- or acetazolamide-loop diuretic combinations increased urine output significantly, leading to a negative fluid balance and weight loss.
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Affiliation(s)
- Jean-Maxime Côté
- Division of Nephrology, Centre hospitalier de l'Université de Montréal, Montréal, Canada; Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Canada; Clinical Research Centre, University College Dublin, Ireland.
| | - Josée Bouchard
- Division of Nephrology, Hôpital du Sacré-Cœur de Montréal, Montréal, Canada
| | - Patrick T Murray
- Clinical Research Centre, University College Dublin, Ireland; School of medicine, Division of Nephrology, Mater Misericordiae University Hospital, Ireland
| | - William Beaubien-Souligny
- Division of Nephrology, Centre hospitalier de l'Université de Montréal, Montréal, Canada; Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Canada
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21
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Kumar R, Priyadarshi RN, Anand U. Chronic renal dysfunction in cirrhosis: A new frontier in hepatology. World J Gastroenterol 2021; 27:990-1005. [PMID: 33776368 PMCID: PMC7985728 DOI: 10.3748/wjg.v27.i11.990] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2020] [Revised: 01/17/2021] [Accepted: 03/09/2021] [Indexed: 02/06/2023] Open
Abstract
Chronic kidney disease (CKD) in patients with liver cirrhosis has become a new frontier in hepatology. In recent years, a sharp increase in the diagnosis of CKD has been observed among patients with cirrhosis. The rising prevalence of risk factors, such as diabetes, hypertension and nonalcoholic fatty liver disease, appears to have contributed significantly to the high prevalence of CKD. Moreover, the diagnosis of CKD in cirrhosis is now based on a reduction in the estimated glomerular filtration rate of < 60 mL/min over more than 3 mo. This definition has resulted in a better differentiation of CKD from acute kidney injury (AKI), leading to its greater recognition. It has also been noted that a significant proportion of AKI transforms into CKD in patients with decompensated cirrhosis. CKD in cirrhosis can be structural CKD due to kidney injury or functional CKD secondary to circulatory and neurohormonal imbalances. The available literature on combined cirrhosis-CKD is extremely limited, as most attempts to assess renal dysfunction in cirrhosis have so far concentrated on AKI. Due to problems related to glomerular filtration rate estimation in cirrhosis, the absence of reliable biomarkers of CKD and technical difficulties in performing renal biopsy in advanced cirrhosis, CKD in cirrhosis can present many challenges for clinicians. With combined hepatorenal dysfunctions, fluid mobilization becomes problematic, and there may be difficulties with drug tolerance, hemodialysis and decision-making regarding the need for liver vs simultaneous liver and kidney transplantation. This paper offers a thorough overview of the increasingly known CKD in patients with cirrhosis, with clinical consequences and difficulties occurring in the diagnosis and treatment of such patients.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Rajeev Nayan Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
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22
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El Iskandarani M, El Kurdi B, Murtaza G, Paul TK, Refaat MM. Prognostic role of albumin level in heart failure: A systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24785. [PMID: 33725833 PMCID: PMC7969328 DOI: 10.1097/md.0000000000024785] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 01/26/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Hypoalbuminemia (HA) is common in HF, however, its pathophysiology and clinical implications are poorly understood. While multiple studies have been published in the past decade investigating the role of serum albumin in HF, there is still no consensus on the prognostic value of this widely available measure. The objective of this study is to assess the prognostic role of albumin in heart failure (HF) patient. METHODS Unrestricted searches of MEDLINE, EMBASE, Cochrane databases were performed. The results were screened for relevance and eligibility criteria. Relevant data were extracted and analyzed using Comprehensive Meta-Analysis software. The Begg and Mazumdar rank correlation test was utilized to evaluate for publication bias. RESULTS A total of 48 studies examining 44,048 patients with HF were analyzed. HA was found in 32% (95% confidence interval [CI] 28.4%-37.4%) HF patients with marked heterogeneity (I2 = 98%). In 10 studies evaluating acute HF, in-hospital mortality was almost 4 times more likely in HA with an odds ratios (OR) of 3.77 (95% CI 1.96-7.23). HA was also associated with a significant increase in long-term mortality (OR: 1.5; 95% CI: 1.36-1.64) especially at 1-year post-discharge (OR: 2.44; 95% CI: 2.05-2.91; I2 = 11%). Pooled area under the curve (AUC 0.73; 95% CI 0.67-0.78) was comparable to serum brain natriuretic peptide (BNP) in predicting mortality in HF patients. CONCLUSION Our results suggest that HA is associated with significantly higher in-hospital mortality as well as long-term mortality with a predictive accuracy comparable to that reported for serum BNP. These findings suggest that serum albumin may be useful in determining high-risk patients.
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Affiliation(s)
| | | | - Ghulam Murtaza
- Cardiology Division, East Tennessee State University, Johnson City, Tennessee
| | - Timir K. Paul
- Cardiology Division, East Tennessee State University, Johnson City, Tennessee
| | - Marwan M. Refaat
- Cardiology Division, American University of Beirut Faculty of Medicine and Medical Center, Beirut, Lebanon
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Abstract
Heart failure (HF) is one of the major causes of morbidity and mortality in the world. According to a 2019 American Heart Association report, about 6.2 million American adults had HF between 2013 and 2016, being responsible for almost 1 million admissions. As the population ages, the prevalence of HF is anticipated to increase, with 8 million Americans projected to have HF by 2030, posing a significant public health and financial burden. Acute decompensated HF (ADHF) is a syndrome characterized by volume overload and inadequate cardiac output associated with symptoms including some combination of exertional shortness of breath, orthopnea, paroxysmal nocturnal dyspnea (PND), fatigue, tissue congestion (e.g., peripheral edema) and decreased mentation. The pathology is characterized by hemodynamic abnormalities that result in autonomic imbalance with an increase in sympathetic activity, withdrawal of vagal activity and neurohormonal activation (NA) resulting in increased plasma volume in the setting of decreased sodium excretion, increased water retention and in turn an elevation of filling pressures. These neurohormonal changes are adaptive mechanisms which in the short term are associated with increased contractility of the left ventricular (LV) and improvement in cardiac output. But chronically, the failing heart is unable to overcome the excessive pressure and volume leading to worsening HF. The primary symptomatic management of ADHF includes intravenous (IV) diuresis to help with decongestion and return to euvolemic status. Even though diuretics have not been shown to provide any mortality benefit, they have been clinically proven to be of significant benefit in the acute decompensated phase, as well as in chronic management of HF. Loop diuretics remain the mainstay of therapy for symptomatic management of HF with use of thiazide diuretics for synergistic effect in the setting of diuretic resistance. Poor diuretic efficacy has been linked with higher mortality and increased rehospitalizations.
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Affiliation(s)
- Sarabjeet S Suri
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Salpy V Pamboukian
- Division of Cardiovascular Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
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Wiedermann CJ. Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients. Curr Med Res Opin 2020; 36:1961-1973. [PMID: 33090028 DOI: 10.1080/03007995.2020.1840970] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Positive fluid balance is common among critically ill patients and leads to worse outcomes, particularly in sepsis, acute respiratory distress syndrome, and acute kidney injury. Restrictive fluid infusion and active removal of accumulated fluid are being studied as approaches to prevent and treat fluid overload. Use of human albumin solutions has been investigated in different phases of restrictive fluid resuscitation, and this narrative literature review was undertaken to evaluate hypoalbuminemia and the roles of human serum albumin with respect to hypovolemia and its management. METHODS PubMed/EMBASE search terms were: "resuscitation," "fluids," "fluid therapy," "fluid balance," "plasma volume," "colloids," "crystalloids," "albumin," "hypoalbuminemia," "starch," "saline," "balanced salt solution," "gelatin," "goal-directed therapy" (English-language, pre-January 2020). Additional papers were identified by manual searching of reference lists. RESULTS Restrictive fluid administration, plus early vasopressor use, may reduce fluid balance, but in some cases fluid overload cannot be entirely avoided. Deresuscitation, with fluid actively removed through diuretics or ultrafiltration, reduces duration of mechanical ventilation and intensive care unit stay. Combining hyperoncotic human albumin solution with diuretics increases hemodynamic stability and diuresis. Hyperoncotic albumin corrects hypoalbuminemia and raises colloid osmotic pressure, limiting edema formation and potentially improving endothelial function. Serum levels of albumin relative to C-reactive protein and lactate may predict which patients will benefit most from albumin therapy. CONCLUSIONS Hyperoncotic human albumin solution facilitates restrictive fluid therapy and the effectiveness of deresuscitative measures. Current evidence is mostly from observational studies, and more randomized trials are needed to better establish a personalized approach to fluid management.
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Affiliation(s)
- Christian J Wiedermann
- Institute of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology, Hall (Tyrol), Austria
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Tang J, Wang Y, Han T, Mao Q, Cheng J, Ding H, Shang J, Zhang Q, Niu J, Ji F, Chen C, Jia J, Jiang X, Lv N, Gao Y, Wang Z, Wei Z, Chen Y, Zeng M, Mao Y. Tolvaptan therapy of Chinese cirrhotic patients with ascites after insufficient diuretic routine medication responses: a phase III clinical trial. BMC Gastroenterol 2020; 20:391. [PMID: 33213378 PMCID: PMC7678173 DOI: 10.1186/s12876-020-01536-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 11/10/2020] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND To determine the safety and efficacy of different doses of tolvaptan for treating Chinese cirrhotic patients with or without hyponatraemia who still had ascites after routine therapy with diuretics. METHODS In the present placebo-controlled, randomized, double-blinded, multicentre clinical trial, patients with cirrhotic ascites who failed to adequately respond to a combination of an aldosterone antagonist plus an orally administered loop diuretic were randomly placed at a 4:2:1 ratio into 3 groups [the 15 mg/day tolvaptan group (N = 301), 7.5 mg/day tolvaptan group (N = 153) and placebo group (N = 76)] for 7 days of treatment. The effects and safety were evaluated on days 4 and 7. A change in body weight from baseline on day 7 of treatment was the primary endpoint. RESULTS The administration of 7.5 or 15 mg/day tolvaptan significantly decreased body weight from baseline on day 7 of treatment compared to that with placebo treatment (P = 0.026; P = 0.001). For the secondary endpoints, changes in abdominal circumference from baseline and improvements in ascites were markedly different in the treatment groups and the placebo group on day 7 (P7.5 = 0.05, P15.0 = 0.002 and P7.5 = 0.037, P15.0 = 0.003), but there was no difference between the 7.5 mg/day and 15 mg/day dosage groups. The 24-h cumulative urine volume was higher in the 7.5 mg/day and 15 mg/day tolvaptan groups than the placebo group (P = 0.002, P < 0.001) and was greater in the 15 mg/day tolvaptan group than the 7.5 mg/day tolvaptan group (P = 0.004). Sodium serum concentrations were higher in patients with hyponatraemia after tolvaptan treatment, with no significant difference between the two dosage groups. The incidence of serious adverse drug reactions was not different between the groups (P = 0.543). CONCLUSIONS Tolvaptan treatment at 7.5 mg per day might be a good therapeutic choice for Chinese cirrhotic patients with ascites who did not achieve satisfactory clinical responses to previous treatment regimens with combination therapy with an aldosterone antagonist and an orally administered loop diuretic. TRIAL REGISTRATION NCT01349348. Retrospectively registered May 2011.
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Affiliation(s)
- Jieting Tang
- School of Medicine Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, No. 145, Middle Shandong Road, Shanghai, 200001, China
| | - Yongfeng Wang
- School of Medicine Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, No. 145, Middle Shandong Road, Shanghai, 200001, China
| | - Tao Han
- Tianjin Third Hospital, Tianjin, China
| | - Qing Mao
- Southwest Hospital, Chongqing, China
| | - Jun Cheng
- Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Huiguo Ding
- Beijing Youan Hospital, Capital Medical University, Beijing, China
| | - Jia Shang
- Henan Provincial Peoples Hospital, Zhengzhou, China
| | - Qin Zhang
- Shanghai Public Health Clinical Center, Shanghai, China
| | - Junqi Niu
- The First Hospital of Jilin University, Changchun, China
| | - Feng Ji
- The First Affiliated Hospital, Zhejiang University, Hangzhou, China
| | - Chengwei Chen
- 85 Hospital of Peoples Liberation Army, Shanghai, China
| | - Jidong Jia
- Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | | | - Nonghua Lv
- The First Affiliated Hospital of Nanchang University, Nanchang, China
| | - Yueqiu Gao
- Shanghai Shuguang Hospital, Shanghai, China
| | - Zhenghua Wang
- School of Medicine Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, No. 145, Middle Shandong Road, Shanghai, 200001, China
| | - Zhong Wei
- School of Medicine Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, No. 145, Middle Shandong Road, Shanghai, 200001, China
| | - Yingxuan Chen
- School of Medicine Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, No. 145, Middle Shandong Road, Shanghai, 200001, China
| | - Minde Zeng
- School of Medicine Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, No. 145, Middle Shandong Road, Shanghai, 200001, China
| | - Yimin Mao
- School of Medicine Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, No. 145, Middle Shandong Road, Shanghai, 200001, China.
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Wichmann S, Barbateskovic M, Lindschou J, Gluud C, Perner A, Bestle MH. Loop diuretics in adult intensive care patients with fluid overload: A protocol for a systematic review of randomised clinical trials with meta-analysis and Trial Sequential Analysis. Acta Anaesthesiol Scand 2020; 64:1327-1334. [PMID: 32531069 DOI: 10.1111/aas.13655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/25/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND In the intensive care unit, fluid overload is frequent and a risk factor for organ dysfunction and increased mortality. Primarily, lung and kidney functions may be impaired by fluid overload resulting in acute respiratory failure and acute kidney injury. No clinical guidelines exist for treatment of fluid overload in intensive care patients. Loop diuretics, most often furosemide, appear to be the most frequently used pharmacological intervention. The aim of this protocol is to describe the methods of a systematic review assessing the evidence of treatment with loop diuretics in adult intensive care patients with fluid overload. METHODS We will conduct a systematic review with meta-analysis and report it according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statements, use the recommendations of the Cochrane Handbook and assess the quality of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. We will include randomised clinical trials identified through searches of major international databases and trial registers. Two authors will independently screen and select trials for inclusion, extract data and assess the methodological quality using the Cochrane risk of bias tool. Extracted data will be analysed using Review Manager and Trial Sequential Analysis. The protocol is registered at PROSPERO. DISCUSSION We aim to provide reliable evidence on the use of loop diuretics in adult intensive care patients with fluid overload to guide clinicians, decision makers and trialists on clinical practice.
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Affiliation(s)
- Sine Wichmann
- Department of Anaesthesiology Nordsjællands HospitalUniversity of Copenhagen Hillerød Denmark
| | - Marija Barbateskovic
- 2Copenhagen Trial Unit Centre for Clinical Intervention Research, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Jane Lindschou
- 2Copenhagen Trial Unit Centre for Clinical Intervention Research, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Christian Gluud
- 2Copenhagen Trial Unit Centre for Clinical Intervention Research, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Morten H. Bestle
- Department of Anaesthesiology Nordsjællands HospitalUniversity of Copenhagen Hillerød Denmark
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Trautmann A, Vivarelli M, Samuel S, Gipson D, Sinha A, Schaefer F, Hui NK, Boyer O, Saleem MA, Feltran L, Müller-Deile J, Becker JU, Cano F, Xu H, Lim YN, Smoyer W, Anochie I, Nakanishi K, Hodson E, Haffner D. IPNA clinical practice recommendations for the diagnosis and management of children with steroid-resistant nephrotic syndrome. Pediatr Nephrol 2020; 35:1529-1561. [PMID: 32382828 PMCID: PMC7316686 DOI: 10.1007/s00467-020-04519-1] [Citation(s) in RCA: 156] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 02/07/2020] [Accepted: 02/21/2020] [Indexed: 02/06/2023]
Abstract
Idiopathic nephrotic syndrome newly affects 1-3 per 100,000 children per year. Approximately 85% of cases show complete remission of proteinuria following glucocorticoid treatment. Patients who do not achieve complete remission within 4-6 weeks of glucocorticoid treatment have steroid-resistant nephrotic syndrome (SRNS). In 10-30% of steroid-resistant patients, mutations in podocyte-associated genes can be detected, whereas an undefined circulating factor of immune origin is assumed in the remaining ones. Diagnosis and management of SRNS is a great challenge due to its heterogeneous etiology, frequent lack of remission by further immunosuppressive treatment, and severe complications including the development of end-stage kidney disease and recurrence after renal transplantation. A team of experts including pediatric nephrologists and renal geneticists from the International Pediatric Nephrology Association (IPNA), a renal pathologist, and an adult nephrologist have now developed comprehensive clinical practice recommendations on the diagnosis and management of SRNS in children. The team performed a systematic literature review on 9 clinically relevant PICO (Patient or Population covered, Intervention, Comparator, Outcome) questions, formulated recommendations and formally graded them at a consensus meeting, with input from patient representatives and a dietician acting as external advisors and a voting panel of pediatric nephrologists. Research recommendations are also given.
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Affiliation(s)
- Agnes Trautmann
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Marina Vivarelli
- Department of Pediatric Subspecialties, Division of Nephrology and Dialysis, Bambino Gesù Pediatric Hospital and Research Center, Rome, Italy
| | - Susan Samuel
- Department of Pediatrics, Section of Pediatric Nephrology, Alberta Children's Hospital, University of Calgary, Calgary, Canada
| | - Debbie Gipson
- Division of Nephrology, University of Michigan, Ann Arbor, MI, USA
| | - Aditi Sinha
- Department of Pediatrics, Division of Nephrology, All India Institute of Medical Sciences, New Delhi, India
| | - Franz Schaefer
- Division of Pediatric Nephrology, Center for Pediatrics and Adolescent Medicine, Heidelberg, Germany
| | - Ng Kar Hui
- Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Olivia Boyer
- Laboratory of Hereditary Kidney Diseases, Imagine Institute, INSERM U1163, Paris Descartes University, Paris, France
- Department of Pediatric Nephrology, Reference Center for Idiopathic Nephrotic Syndrome in Children and Adults, Necker Hospital, APHP, 75015, Paris, France
| | - Moin A Saleem
- Department of Pediatric Nephrology, Bristol Royal Hospital for Children, University of Bristol, Bristol, UK
| | - Luciana Feltran
- Hospital Samaritano and HRim/UNIFESP, Federal University of São Paulo, São Paulo, Brazil
| | | | - Jan Ulrich Becker
- Institute of Pathology, University Hospital of Cologne, Cologne, Germany
| | - Francisco Cano
- Department of Nephrology, Luis Calvo Mackenna Children's Hospital, University of Chile, Santiago, Chile
| | - Hong Xu
- Department of Nephrology, Children's Hospital of Fudan University, Shanghai, China
| | - Yam Ngo Lim
- Department of Pediatrics, Prince Court Medical Centre, Kuala Lumpur, Malaysia
| | - William Smoyer
- The Research Institute at Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Ifeoma Anochie
- Department of Paediatrics, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
| | - Koichi Nakanishi
- Department of Child Health and Welfare (Pediatrics), Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Elisabeth Hodson
- Cochrane Kidney and Transplant, Centre for Kidney Research, The Children's Hospital at Westmead and the Sydney School of Public Health, University of Sydney, Sydney, Australia
| | - Dieter Haffner
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Hannover Medical School Children's Hospital, Hannover, Germany.
- Department of Paediatric Kidney, Liver and Metabolic Diseases, Paediatric Research Center, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- Center for Rare Diseases, Hannover Medical School Children's Hospital, Hannover, Germany.
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Gong S, Dong Y, Gunderson TM, Andrijasevic NM, Kashani KB. Elastic Bandage vs Hypertonic Albumin for Diuretic-Resistant Volume-Overloaded Patients in Intensive Care Unit: A Propensity-Match Study. Mayo Clin Proc 2020; 95:1660-1670. [PMID: 32605782 DOI: 10.1016/j.mayocp.2020.03.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 03/03/2020] [Accepted: 03/09/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To compare elastic bandage (EB) vs hypertonic albumin solution administration to increase fluid removal by enhancing loop diuretic efficiency (DE) in patients with volume overload and diuretic resistance. PATIENTS AND METHODS In this historic cohort study with propensity matching, we included diuretic-resistant adult (≥18 years) patients with volume overload after fluid resuscitation admitted in the intensive care unit from January 1, 2006, through June 30, 2017. Regression models and propensity matching were used to assess the associations of these interventions with changes in DE and other clinical outcomes. RESULTS Of 1147 patients (median age, 66; interquartile range [IQR], 56-76 years; 51% [n=590] men), 384 (33%) received EB and 763 (67%) received hypertonic albumin solution. In adjusted models, EB was significantly associated with higher DE compared with hypertonic albumin solution (odds ratio, 1.37; 95% CI, 1.04 to 1.81; P=.004). After propensity matching of 345 pairs, DE remained significantly different between the 2 groups (median, 2111; IQR, 1092 to 4665 mL for EB vs median, 1829; IQR, 1032 to 3436 mL for hypertonic albumin solution; P=.02). EB, male sex, lower baseline serum urea nitrogen level, lower Charlson Comorbidity Index score, and higher baseline left ventricular ejection fraction were DE determinants. The lowest DE quartile (<1073 mL/40-mg furosemide equivalent) following adjustment for known predictors of mortality remained independently associated with higher 90-day death rate (odds ratio, 1.64; 95% CI, 1.13 to 2.36; P=.009). CONCLUSION EB use is associated with greater DE than hypertonic albumin solution during the deescalation phase of sepsis resuscitation. Prospective clinical trials would validate the findings of this hypothesis-generating study.
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Affiliation(s)
- Shurong Gong
- Department of Surgical Critical Care Medicine, Fujian Provincial Hospital, Provincial Clinical College of Fujian Medical University, Fuzhou, China
| | - Yue Dong
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Tina M Gunderson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN
| | | | - Kianoush B Kashani
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN.
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Bissell BD, Donaldson JC, Morris PE, Neyra JA. A narrative review of pharmacologic de-resuscitation in the critically ill. J Crit Care 2020; 59:156-162. [PMID: 32674002 DOI: 10.1016/j.jcrc.2020.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/28/2020] [Accepted: 07/03/2020] [Indexed: 02/06/2023]
Abstract
Despite evidence highlighting harms of fluid overload, minimal guidance exists on counteraction via utilization of diuretics in the de-resuscitation phase. While diuretics have been shown to decrease net volume and improve clinical outcomes in the critically ill, a lack of standardization surrounding selection of diuretic regimen or monitoring of de-resuscitation exists. Current monitoring parameters of de-resuscitation often rely on clinical signs of fluid overload, end organ recovery and other biochemical surrogate markers which are often deemed unreliable. The majority of evidence suggests that achieving a net-negative fluid balance within 72 h after shock resolution may be of benefit; however, approaches to such goal are uncertain. Loop diuretics are a widely available type of diuretic for removal of volume in patients with sufficient kidney function, with the potential for adjunct diuretics in special circumstances. At present, administration of diuretics within the broad critically ill population fails to find uniformity and often efficacy. Given the lack of randomized controlled trials in this susceptible population, we aim to provide a thorough therapeutic understanding of diuretic pharmacotherapy which is necessary in order to achieve desired goal of fluid balance and improve overall outcomes.
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Affiliation(s)
- Brittany D Bissell
- University of Kentucky College of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, 740 South Limestone, Lexington, Kentucky 40536, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, 789 South Limestone, Lexington, Kentucky 40536, United States of America.
| | - J Chris Donaldson
- University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, 789 South Limestone, Lexington, Kentucky 40536, United States of America.
| | - Peter E Morris
- University of Kentucky College of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, 740 South Limestone, Lexington, Kentucky 40536, United States of America.
| | - Javier A Neyra
- University of Kentucky College of Medicine, Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, 740 South Limestone, Lexington, Kentucky 40536, United States of America.
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Chen JJ, Chang CH, Huang YT, Kuo G. Furosemide stress test as a predictive marker of acute kidney injury progression or renal replacement therapy: a systemic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:202. [PMID: 32381019 PMCID: PMC7206785 DOI: 10.1186/s13054-020-02912-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 04/22/2020] [Indexed: 12/16/2022]
Abstract
Background The use of the furosemide stress test (FST) as an acute kidney injury (AKI) severity marker has been described in several trials. However, the diagnostic performance of the FST in predicting AKI progression has not yet been fully discussed. Methods In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched the PubMed, Embase, and Cochrane databases up to March 2020. The diagnostic performance of the FST (in terms of sensitivity, specificity, number of events, true positive, false positive) was extracted and evaluated. Results We identified eleven trials that enrolled a total of 1366 patients, including 517 patients and 1017 patients for whom the outcomes in terms of AKI stage progression and renal replacement therapy (RRT), respectively, were reported. The pooled sensitivity and specificity results of the FST for AKI progression prediction were 0.81 (95% CI 0.74–0.87) and 0.88 (95% CI 0.82–0.92), respectively. The pooled positive likelihood ratio (LR) was 5.45 (95% CI 3.96–7.50), the pooled negative LR was 0.26 (95% CI 0.19–0.36), and the pooled diagnostic odds ratio (DOR) was 29.69 (95% CI 17.00–51.85). The summary receiver operating characteristics (SROC) with pooled diagnostic accuracy was 0.88. The diagnostic performance of the FST in predicting AKI progression was not affected by different AKI criteria or underlying chronic kidney disease. The pooled sensitivity and specificity results of the FST for RRT prediction were 0.84 (95% CI 0.72–0.91) and 0.77 (95% CI 0.64–0.87), respectively. The pooled positive LR and pooled negative LR were 3.16 (95% CI 2.06–4.86) and 0.25 (95% CI 0.14–0.44), respectively. The pooled diagnostic odds ratio (DOR) was 13.59 (95% CI 5.74–32.17), and SROC with pooled diagnostic accuracy was 0.86. The diagnostic performance of FST for RRT prediction is better in stage 1–2 AKI compared to stage 3 AKI (relative DOR 5.75, 95% CI 2.51–13.33). Conclusion The FST is a simple tool for the identification of AKI populations at high risk of AKI progression and the need for RRT, and the diagnostic performance of FST in RRT prediction is better in early AKI population.
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Affiliation(s)
- Jia-Jin Chen
- Department of Nephrology, Chang Gung Memorial Hospital, No 5 Fu-shin Street, Taoyuan City, 333, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Chang Gung Memorial Hospital, No 5 Fu-shin Street, Taoyuan City, 333, Taiwan.,Department of Nephrology, Kidney Research Center, Chang Gung Memorial Hospital, Taoyuan City, 333, Taiwan
| | - Yen-Ta Huang
- Division of Experimental Surgery, Department of Surgery, Buddhist Tzu Chi General Hospital, Hualien County, 970, Taiwan.,Department of Pharmacology, School of Medicine, Tzu Chi University, Hualien County, 970, Taiwan
| | - George Kuo
- Department of Nephrology, Chang Gung Memorial Hospital, No 5 Fu-shin Street, Taoyuan City, 333, Taiwan.
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Efficacy of furosemide-albumin compared with furosemide in critically ill hypoalbuminemia patients admitted to intensive care unit: a prospective randomized clinical trial. ACTA ACUST UNITED AC 2020; 28:263-269. [PMID: 32291620 DOI: 10.1007/s40199-020-00339-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Accepted: 03/24/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Some physicians co-administer albumin with loop diuretics to overcome diuretic resistance in critically ill hypoalbuminemia patients, though previous studies have reported conflicting results on this matter. OBJECTIVE The effects of adding albumin to furosemide to enhance its efficacy in critically ill hypoalbuminemia patients are evaluated. METHODS This was a non-blinded randomized trial. 49 adult critically ill patients with hypoalbuminemia and generalized edema who received randomly furosemide and furosemide/albumin complex were enrolled. The patients' urine was collected at intervals of 2, 4, 6 and 8 h after initiation of the furosemide treatment, and the urine output and urinary excretion of furosemide and sodium were measured. The urinary excretion of furosemide was considered an indicator of drug efficacy. RESULTS The amount of sodium and furosemide excreted in urine showed no significant differences between the two groups; however, the mean of the urinary excretion of furosemide in the first 2 h after drug infusion was significantly higher (p = 0.03) in the furosemide/albumin group. No significant correlation between APACHE II scores and serum albumin levels and the urinary excretion of furosemide was seen. CONCLUSION The results indicated that there is not statistically significant differences between groups with furosemide alone and combined with albumin in urinary furosemide excretion. It seems that adding albumin for furosemide pharmacotherapy regime is not recommended as an intervention to increase furosemide efficacy in critically ill hypoalbuminemia patients. TRIAL REGISTRATION IRCT with the registration number IRCT201412132582N12 in 23 February 2015; https://en.irct.ir/trial/2356 Graphical abstract.
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Abstract
Decompensated heart failure accounts for approximately 1 million hospitalizations in the United States annually, and this number is expected to increase significantly in the near future. Diuretics provide the initial management in most patients with fluid overload. However, the development of diuretic resistance remains a significant challenge in the treatment of heart failure. Due to the lack of a standard definition, the prevalence of this phenomenon remains difficult to determine, with some estimates suggesting that 25-30% of patients with heart failure have diuretic resistance. Certain characteristics, including low systolic blood pressures, renal impairment, and atherosclerotic disease, help predict the development of diuretic resistance. The underlying pathophysiology is likely multifactorial, with pharmacokinetic alterations, hormonal dysregulation, and the cardiorenal syndrome having significant roles. The therapeutic approach to this common problem typically involves increases in the diuretic dose and/or frequency, sequential nephron blockade, and mechanical fluid movement removal with ultrafiltration or peritoneal dialysis. Paracentesis is potentially useful in patients with intra-abdominal hypertension.
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Felker GM, Ellison DH, Mullens W, Cox ZL, Testani JM. Diuretic Therapy for Patients With Heart Failure. J Am Coll Cardiol 2020; 75:1178-1195. [DOI: 10.1016/j.jacc.2019.12.059] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/15/2019] [Accepted: 12/02/2019] [Indexed: 12/12/2022]
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Abstract
How to cite this article: Hegde A. Diuretics in Acute Kidney Injury. Indian J Crit Care Med 2020;24(Suppl 3):S98–S99.
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Affiliation(s)
- Ashit Hegde
- Department of Medicine and Critical Care, P.D. Hinduja Hospital and Medical Research Centre, Mumbai, Maharashtra, India
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Zeng L, Tian M, Chen SS, Ke YT, Geng L, Yang SL, Ye L. Short-term Outcomes of Laparoscopic vs. Open Hepatectomy for Primary Hepatocellular Carcinoma: A Prospective Comparative Study. Curr Med Sci 2019; 39:778-783. [PMID: 31612396 DOI: 10.1007/s11596-019-2105-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 09/03/2019] [Indexed: 02/06/2023]
Abstract
Laparoscopic hepatectomy (LH) is a newly developed technique associated with advantages as open surgery, but the study on outcome of liver function recovery was scarce. This preliminary report was aimed to comparatively assess the short-term outcomes between LH and open hepatectomy (OH) for primary hepatocellular carcinoma (PHC). This study retrospectively analyzed the demographic data and short-term outcomes of 81 patients who underwent LH or OH for the primary treatment of PHC between Oct. 2017 and May 2018 at Union Hospital, Tongji Medical College, Huazhong University of Science and Technology (China). A total of 81 PHC patients who received major liver resection were enrolled. There were 38 (47%) patients in the LH group and 43 (53%) patients in the OH group. The operative time was significantly longer (373.53±173.38 vs. 225.43±55.08, P<0.01), and hospital stay (17.34±5.93 vs. 21.70±6.89, P=0.003), exhaust time (2.32±0.62 vs. 3.07±0.59, P<0.01) and defecation time (2.92±0.78 vs. 3.63±0.58, P<0.01) were significantly shorter in LH group than in OH group. The recovery of liver function was significantly faster in LH group, including higher serum albumin (P=0.002), higher ratio of albumin/globulin (P=0.029) and lower direct bilirubin (P=0.001) than in OH group. It is suggested that LH can serve as a fast recovery and cheap surgical procedure in the treatment of PHC, which is safe and feasible.
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Affiliation(s)
- Li Zeng
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Min Tian
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Si-Si Chen
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Yu-Ting Ke
- Department of Hepatobiliary Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Li Geng
- Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Sheng-Li Yang
- Cancer Center, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
| | - Lin Ye
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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Mariano F, Mella A, Vincenti M, Biancone L. Furosemide as a functional marker of acute kidney injury in ICU patients: a new role for an old drug. J Nephrol 2019; 32:883-893. [PMID: 31090022 DOI: 10.1007/s40620-019-00614-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Accepted: 04/16/2019] [Indexed: 12/21/2022]
Abstract
New pharmacokinetics insight suggests that the furosemide pharmacology occurring in ICU patients with AKI is similar, but not equal to that described in chronic stable renal patients. Even if the diuretic response to furosemide is expressed by a steep dose-response curve positively correlated with renal function, pharmacodynamic limitations occur when creatinine clearance is < 20 ml/min or urine output is < 500 ml/12 h. In such cases, other factors specifically due to acute tubular injury can interfere with the furosemide-induced diuretic output. As modality of administration recent reports and metanalysis, even if not conclusive, suggest that for the same given dose a continuous infusion of furosemide was superior in diuretic response. For septic shock patients on CVVHDF where treatment adds an additional clearance of furosemide the maximum diuretic response is achieved by a continuous infusion of 20 mg/h of furosemide. At this infusion rate the reached plasma level was < 20 mg/L, a range considered safe and not ototoxic. Therefore, the severity of AKI establishes whether a patient will respond to furosemide. In this review we summarized all these recent updates, also suggesting that the diuretic response under continuous infusion may allow assessing glomerular and tubular functions with increased reliability than a bolus dose. However, validation studies are still needed to support continuous infusion as a stress test.
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Affiliation(s)
- Filippo Mariano
- Nephrology, Dialysis and Transplantation U, Department of Medical Sciences, CTO Hospital, University of Turin, City of Health and Science, Via G. Zuretti 29, 10126, Turin, Italy.
| | - Alberto Mella
- Nephrology, Dialysis and Transplantation U, Department of Medical Sciences, CTO Hospital, University of Turin, City of Health and Science, Via G. Zuretti 29, 10126, Turin, Italy
| | - Marco Vincenti
- Department of Chemistry, University of Turin, Turin, Italy
| | - Luigi Biancone
- Nephrology, Dialysis and Transplantation U, Department of Medical Sciences, CTO Hospital, University of Turin, City of Health and Science, Via G. Zuretti 29, 10126, Turin, Italy
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Affiliation(s)
- David H Ellison
- Departments of Medicine and Physiology and Pharmacology, Oregon Health & Science University, Portland, Oregon; and Renal Section, Veterans Affairs Portland Health Care System, Portland, Oregon
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Joannidis M, Klein SJ, Ostermann M. 10 myths about frusemide. Intensive Care Med 2019; 45:545-548. [PMID: 30643933 DOI: 10.1007/s00134-018-5502-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Accepted: 12/08/2018] [Indexed: 12/14/2022]
Affiliation(s)
- Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria.
| | - Sebastian J Klein
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstr. 35, 6020, Innsbruck, Austria
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, Guy's and St Thomas' Hospital, London, UK
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Jardim SI, Ramos dos Santos L, Araújo I, Marques F, Branco P, Gaspar A, Fonseca C. A 2018 overview of diuretic resistance in heart failure. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.repce.2018.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
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Jardim SI, Ramos dos Santos L, Araújo I, Marques F, Branco P, Gaspar A, Fonseca C. A 2018 overview of diuretic resistance in heart failure. Rev Port Cardiol 2018; 37:935-945. [DOI: 10.1016/j.repc.2018.03.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 02/18/2018] [Accepted: 03/11/2018] [Indexed: 01/01/2023] Open
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Jacobs R, Jonckheer J, Malbrain MLNG. Fluid overload FADEs away! Time for fluid stewardship. J Crit Care 2018; 48:458-461. [PMID: 30172416 DOI: 10.1016/j.jcrc.2018.08.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 08/20/2018] [Accepted: 08/20/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Rita Jacobs
- From the Department of Intensive Care Medicine, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Joop Jonckheer
- From the Department of Intensive Care Medicine, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium
| | - Manu L N G Malbrain
- From the Department of Intensive Care Medicine, University Hospital Brussels, Laarbeeklaan 101, 1090 Jette, Belgium; Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel (VUB), Brussels, Belgium.
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Oczkowski SJW, Klotz L, Mazzetti I, Alshamsi F, Chen ML, Foster G, Meade MO, Hamielec C. Furosemide and Albumin for Diuresis of Edema (FADE): A parallel-group, blinded, pilot randomized controlled trial. J Crit Care 2018; 48:462-467. [PMID: 30037660 DOI: 10.1016/j.jcrc.2018.07.020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 07/16/2018] [Accepted: 07/16/2018] [Indexed: 12/31/2022]
Abstract
PURPOSE To assess the feasibility of a trial evaluating whether hyperoncotic albumin, in addition to diuretics, improves diuresis and facilitates liberation from mechanical ventilation in critically ill adults. MATERIALS AND METHODS We randomized 46 hemodynamically stable patients with hypoalbuminemia, prescribed diuretics by treating clinicians, to receive 100 mL of 25% albumin or 0.9% saline placebo BID, for three days, in blinded fashion. We chose five feasibility measurements: enrolment of 50% of eligible patients, at least one patient/week; administration of study treatment within 2 h of diuretics in 85% of patients; completion of study regimen in 80% of patients; and avoidance of open label albumin in 85% of patients. Clinical outcomes included fluid balance, ventilator-free days, and mortality. RESULTS We randomized 85% of eligible patients. Eighty-four percent received study treatment within 2 h of diuretics, 69% received all doses of study treatment. Study treatment was held in the albumin and placebo groups because of no further need for diuresis (4 vs. 1), hypotension (2 v. 4), and albumin > 35 (1 v. 0). Twenty percent of patients received open-label albumin. Clinical outcomes were similar between groups. CONCLUSIONS The current study design did not demonstrate feasibility, but can inform the design of a definitive trial.
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Affiliation(s)
- Simon J W Oczkowski
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Canada; Department of Critical Care, Hamilton Health Sciences, Canada.
| | - Lisa Klotz
- Department of Critical Care, Hamilton Health Sciences, Canada
| | - Ian Mazzetti
- Schulich School of Medicine and Dentistry, Western University, Canada
| | - Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Mei Lin Chen
- Department of Health Sciences Honours, Faculty of Health Sciences, McMaster University, Canada
| | - Gary Foster
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada; Biostatistics Unit, The Research Institute, St. Joseph's Healthcare, Hamilton, Canada
| | - Maureen O Meade
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Canada; Department of Critical Care, Hamilton Health Sciences, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Canada
| | - Cindy Hamielec
- Division of Critical Care Medicine, Department of Medicine, McMaster University, Canada; Department of Critical Care, Hamilton Health Sciences, Canada
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Ellison DH. Treatment of Disorders of Sodium Balance in Chronic Kidney Disease. Adv Chronic Kidney Dis 2017; 24:332-341. [PMID: 29031361 DOI: 10.1053/j.ackd.2017.07.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 07/25/2017] [Indexed: 12/23/2022]
Abstract
Extracellular fluid volume expansion is nearly universal in patients with CKD. Such volume expansion has features similar to the syndrome of heart failure with preserved ejection fraction, which not only leads to symptoms but can also lead to further organ damage. Unique treatment challenges are present in this patient population, including low glomerular filtration, which limits sodium chloride filtration, intrinsic tubule predisposition to sodium chloride retention, and proteinuria. In addition, pharmacokinetic considerations alter the disposition of diuretics in patients with CKD and nephrotic syndrome. Maintaining extracellular fluid volume near to normal is often necessary for hypertension treatment in this population, but it may also help prevent progressive cardiovascular and kidney damage. Although powerful diuretics can often accomplish this goal, this often comes at a cost of competing adverse effects. An approach to reduce extracellular fluid volume while avoiding adverse effects, therefore, requires a nuanced yet aggressive therapeutic approach.
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Population pharmacokinetic modeling of furosemide in patients with hypertension and fluid overload conditions. Pharmacol Rep 2017; 69:492-496. [DOI: 10.1016/j.pharep.2017.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2016] [Revised: 01/11/2017] [Accepted: 01/13/2017] [Indexed: 11/29/2022]
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de Toledo LAK, Noblat ACB, do Nascimento HF, Noblat LDACB. Economic evaluation of human albumin use in patients with nephrotic syndrome in four Brazilian public hospitals: pharmacoeconomic study. SAO PAULO MED J 2017; 135:92-99. [PMID: 28443947 PMCID: PMC9977339 DOI: 10.1590/1516-3180.2016.0048030516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 05/03/2016] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE: In 2004, the Brazilian National Health Surveillance Agency (Agência Nacional de Vigilância Sanitária, ANVISA) published a resolution establishing guidelines for albumin use. Although the published data do not indicate any definitive conclusions about the benefits of albumin use in patients with nephrotic syndrome (NS), the guidelines recommend this procedure only in cases of edema that is refractory to use of diuretics. The aim here was to analyze albumin use among patients with nephrotic syndrome. DESIGN AND SETTING: Pharmacoeconomic study conducted in four large public referral hospitals for nephrology services in northeastern Brazil. METHOD: Cost-effectiveness and cost-utility economic evaluations were performed on a concurrent cohort of patients with nephrotic syndrome, who were divided into two groups according to compliance or noncompliance with the guidelines. Quality-of-life data were obtained from the SF36 and CHQ-PF50 questionnaires. RESULTS: This study enrolled 109 patients (60% adults and 56% women); 41.3% were using albumin in accordance with the guidelines. The weight, diuresis and fluid balance parameters were more cost-effective for patients who adhered to the guidelines. Regarding days of hospitalization avoided, the incremental ratio showed a daily cost of R$ 55.33, and guideline-compliant patients were hospitalized for five days or fewer. The quality of life improved by 8%, and savings of R$ 3,458.13/QALY (quality-adjusted life year) for the healthcare system were generated through guideline compliance. CONCLUSION: The economic analyses of this study demonstrated that there were greater cost benefits for patients whose treatment followed the guidelines.
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Affiliation(s)
- Leonardo Augusto Kister de Toledo
- MSc. Pharmacist, Hospital Universitário Professor Edgard Santos (HUPES), Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil.
| | - Antônio Carlos Beisl Noblat
- MD, PhD. Nephrologist, Head of Complex Care Management Division, Hospital Universitário Professor Edgard Santos (HUPES), Universidade Federal da Bahia (UFBA), Salvador (BA), Brazil.
| | | | - Lúcia de Araújo Costa Beisl Noblat
- Pharmacyst, PhD. Professor, School of Pharmacy, Universidade Federal da Bahia (UFBA), and Education and Research Manager, Hospital Universitário Professor Edgard Santos (HUPES), Salvador (BA), Brazil.
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Mori T, Ohsaki Y, Oba-Yabana I, Ito S. Diuretic usage for protection against end-organ damage in liver cirrhosis and heart failure. Hepatol Res 2017; 47:11-22. [PMID: 26990144 DOI: 10.1111/hepr.12700] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2016] [Revised: 03/09/2016] [Accepted: 03/10/2016] [Indexed: 02/08/2023]
Abstract
Volume overload is common in liver cirrhosis, heart failure, and chronic kidney disease, being an independent risk factor for mortality. Loop diuretics have been widely used for treating volume overload in these patients. However, there is a tendency to increase the dose of loop diuretics partly because of diuresis resistance. Neurohormonal factors are also enhanced in these patients, which play a role in volume overload and organ ischemia. Loop diuretics cannot improve neurohormonal factors and could result in end-organ damage. The water diuretic tolvaptan has been approved for use for volume overload in heart failure and liver cirrhosis. Despite causing similar increases in urine volume, its characteristics differ from those of loop diuretics. Renal blood flow is maintained with tolvaptan but decreased with furosemide in heart failure patients. Neurohormonal factors and blood pressure are not markedly altered by tolvaptan administration. It is expected that these mechanisms of tolvaptan can protect against worsening renal function by volume overload diseases compared with loop diuretics. It has also been reported that some patients do not respond well to tolvaptan. Loop diuretics and tolvaptan share the same mechanism with regard to decreasing renal interstitial osmolality, which plays a fundamental role in water diuresis. Thus, a high dose of loop diuretics could result in resistance to tolvaptan, so tolvaptan should be administered before increasing the loop diuretic dose. Therefore, volume control without enhancing end-organ damage can be achieved by adding tolvaptan to a tolerable dose of Na-sparing diuretics.
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Affiliation(s)
- Takefumi Mori
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Integrative Renal Replacement Therapy, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Nephrology and Endocrinology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Yusuke Ohsaki
- Division of Integrative Renal Replacement Therapy, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Nephrology and Endocrinology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Ikuko Oba-Yabana
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Integrative Renal Replacement Therapy, Tohoku University Graduate School of Medicine, Sendai, Japan.,Division of Nephrology and Endocrinology, Tohoku Medical and Pharmaceutical University, Sendai, Japan
| | - Sadayoshi Ito
- Division of Nephrology, Endocrinology, and Vascular Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
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Hypertension in CKD Pregnancy: a Question of Cause and Effect (Cause or Effect? This Is the Question). Curr Hypertens Rep 2016; 18:35. [PMID: 27072828 DOI: 10.1007/s11906-016-0644-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Chronic kidney disease (CKD) is increasingly encountered in pregnancy, and hypertension is frequently concomitant. In pregnancy, the prevalence of CKD is estimated to be about 3%, while the prevalence of chronic hypertension is about 5-8%. The prevalence of hypertension and CKD in pregnancy is unknown. Both are independently related to adverse pregnancy outcomes, and the clinical picture merges with pregnancy-induced hypertension and preeclampsia. Precise risk quantification is not available, but risks linked to CKD stage, hypertension, and proteinuria are probably multiplicative, each at least doubling the rates of preterm and early preterm delivery, small for gestational age babies, and related outcomes. Differential diagnosis (based upon utero-placental flows, fetal growth, and supported by serum biomarkers) is important for clinical management. In the absence of guidelines for hypertension in CKD pregnancies, the ideal blood pressure goal has not been established; we support a tailored approach, depending on compliance, baseline control, and CKD stages, with strict blood pressure monitoring. The choice of antihypertensive drugs and the use of diuretics and of erythropoiesis-stimulating agents (ESAs) are still open questions which only future studies may clarify.
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Abstract
OBJECTIVES Focusing on critically ill children with cardiac disease, we will review common causes of fluid perturbations, clinical recognition, and strategies to minimize and treat fluid-related complications. DATA SOURCE MEDLINE and PubMed. CONCLUSIONS Meticulous fluid management is vital in critically ill children with cardiac disease. Fluid therapy is important to maintain adequate blood volume and perfusion pressure in order to support cardiac output, tissue perfusion, and oxygen delivery. However, fluid overload and acute kidney injury are common and are associated with increased morbidity and mortality. Understanding the etiologies for disturbances in volume status and the pathophysiology surrounding those conditions is crucial for providing optimal care.
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Okabe T, Yakushiji T, Igawa W, Ono M, Kido T, Ebara S, Yamashita K, Yamamoto MH, Saito S, Hoshimoto K, Amemiya K, Isomura N, Araki H, Ochiai M. The Efficacy of Tolvaptan in Congestive Heart Failure Patients with and Without Hypoalbuminemia: A Pilot Study. Cardiovasc Ther 2016; 33:275-81. [PMID: 26122275 DOI: 10.1111/1755-5922.12142] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
BACKGROUND Heart failure (HF) with hypoalbuminemia is associated with poor response to conventional therapy. We investigated whether tolvaptan, a potent aquaretic agent, might be of benefit in HF patients with hypoalbuminemia. METHODS We prospectively enrolled 40 patients hospitalized for HF. Patients received conventional therapy including loop diuretics. We subsequently added tolvaptan in the range of 3.75-15 mg daily and it was discontinued after improvement of HF symptoms. We compared clinical and laboratory data in HF patients with and without hypoalbuminemia (defined as serum albumin <3.0 g/dL). RESULTS Tolvaptan was administered in 18 HF patients with hypoalbuminemia (Group A) and 22 HF patients without hypoalbuminemia (Group B). The mean serum albumin was 2.63 ± 0.27 and 3.46 ± 0.25 g/dL, respectively. The average urine output on tolvaptan increased significantly in both groups (1644.4 ± 797.6-3011.6 ± 1453.8 mL/day, P = 0.004; 1459 ± 612.7-2112.2 ± 724.5 mL/day, P = 0.008; respectively). In addition, we observed higher urine output on therapy in Group A than in Group B (P = 0.015). There was a moderate negative correlation between serum albumin and average urine output on tolvaptan (r = -0.42, P = 0.007). CONCLUSIONS The addition of tolvaptan to low dose loop diuretics might be an effective strategy for treatment of HF patients with hypoalbuminemia.
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Affiliation(s)
- Toshitaka Okabe
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Tadayuki Yakushiji
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Wataru Igawa
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Morio Ono
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Takehiko Kido
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Seitaro Ebara
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Kennosuke Yamashita
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Myong Hwa Yamamoto
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Shigeo Saito
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Koichi Hoshimoto
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Kisaki Amemiya
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Naoei Isomura
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Hiroshi Araki
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
| | - Masahiko Ochiai
- Division of Cardiology and Cardiac Catheterization Laboratories, Showa University Northern Yokohama Hospital, Tsuzuki, Yokohama, Japan
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Fluid Management. Pediatr Crit Care Med 2016; 17:S35-48. [PMID: 26945328 DOI: 10.1097/pcc.0000000000000633] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVE In this Consensus Statement, we review the etiology and pathophysiology of fluid disturbances in critically ill children with cardiac disease. Clinical tools used to recognize pathologic fluid states are summarized, as are the mechanisms of action of many drugs aimed at optimal fluid management. DATA SOURCES The expertise of the authors and a review of the medical literature were used as data sources. DATA SYNTHESIS The authors synthesized the data in the literature in order to present clinical tools used to recognize pathologic fluid states. For each drug, the physiologic rationale, mechanism of action, and pharmacokinetics are synthesized, and the evidence in the literature to support the therapy is discussed. CONCLUSIONS Fluid management is challenging in critically ill pediatric cardiac patients. A myriad of causes may be contributory, including intrinsic myocardial dysfunction with its associated neuroendocrine response, renal dysfunction with oliguria, and systemic inflammation with resulting endothelial dysfunction. The development of fluid overload has been associated with adverse outcomes, including acute kidney injury, prolonged mechanical ventilation, increased vasoactive support, prolonged hospital length of stay, and mortality. An in-depth understanding of the many factors that influence volume status is necessary to guide optimal management.
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