Renal dysfunction in heart failure

Correlation Between Cystatin C and the Severity of Cardiac Dysfunction in Patients with Systolic Heart Failure

Introduction

To investigate the relationship between cystatin C and cardiac dysfunction severity in patients with systolic heart failure.

Methods

We recruited 100 hospitalized patients with systolic heart failure and 100 age-gender-matched controls. The clinical information of each patient was collected. Blood pressure, heart rate, height, and weight were measured, as were serum concentrations of cholesterol, renal function indices, cystatin C, and B-type natriuretic peptide (BNP). Transthoracic echocardiography was performed on each patient.

Results

Cystatin C and other indices of renal function, such as urea nitrogen, creatinine, and uric acid, were significantly elevated in the serum of patients with heart failure and those with more severe cardiac dysfunction. The stepwise regression analyses showed that cystatin C was positively associated with BNP (β = 0.18, P = 0.04, 95% CI: 21.1 ~ 1420.4) and left atrial diameter (LAD) (β = 0.19, P = 0.04, 95% CI: 0.03 ~ 9.21) and was negatively associated with ejection fraction (β = -0.22, P = 0.023, 95% CI: -12.4 ~ -0.93), while creatinine was only positively correlated with BNP (β = 0.23, P = 0.03, 95% CI: 1.11 ~ 20.7). The Receiver Operating Characteristic (ROC) curves demonstrated significantly more severe cardiac dysfunction (NYHA III/IV) in patients with cystatin C ≥ 0.895mg/L (sensitivity was 83.0%, specificity was 80.9%, AUC = 0.893) and creatinine ≥ 91.5μmol/L (sensitivity was 71.7%, specificity was 70.2%, AUC = 0.764).

Conclusion

Cystatin C was significantly correlated with cardiac structure and function in patients with systolic heart failure, and it was more valuable than creatinine to evaluate the severity of heart failure.

Cardio-renal benefits of sacubitril/valsartan in patients with advanced chronic kidney disease: experience in daily clinical practice

Background

The association between cardiac complications, such as heart failure (HF), and chronic kidney disease (CKD) is well known. In this study, we examined the effectiveness and safety of treatment with neprilysin inhibition in patients with advanced chronic kidney disease (stage 3b-4).

Methods

This single-centre, longitudinal, retrospective study of 31 months duration involved consecutive patients with CKD and HF with a reduced ejection fraction (HFrEF) who started treatment with sacubitril/valsartan. Glomerular filtration rate (GFR), cardiovascular risk factors, proteinuria, potassium, echocardiographic parameters and admissions for heart failure were analysed.

Results

The study comprised 25 patients with a median age of 73.2 ± 5.9 years. The most frequent aetiology of heart failure was ischemic heart disease. The median GFR was 29.4 ± 8.3 ml/min/1.73 m² and the left ventricular ejection fraction (LVEF) 36.4 ± 8.9%. The GFR improved after initiating the treatment (F = 3.396, p = 0.019), as did the LVEF at one year of follow-up (p = 0.018). The number of visits to the emergency department for heart failure was also reduced. No patients needed to start renal replacement therapy.

Conclusions

This study shows that sacubitril/valsartan may play a beneficial role in patients who have advanced CKD and HFrEF, with a satisfactory safety profile.

Diagnostic Values of Blood Urea Nitrogen (BUN), Creatinine (Cr), and the Ratio of BUN to Cr for Distinguishing Heart Failure from Asthma and Chronic Obstructive Pulmonary Disease

Background

In clinical practise, it can be challenging to tell the difference between asthma and chronic obstructive pulmonary disease (COPD) and heart failure (HF), which share comparable dyspnea symptoms. We aimed to examine whether renal function indexes blood urea nitrogen (BUN), creatinine (Cr), and the ratio of BUN to Cr (BUN/Cr) can be used to distinguish HF from asthma and COPD.

Methods

A total of 170 patients were admitted for dyspnea symptoms in this retrospective study. There are 69 patients with HF (HF group), 50 patients with asthma (asthma group), and 51 patients diagnosed with COPD (COPD group). The levels of BUN, Cr, and the ratio of BUN/Cr in the three groups were compared. Student's t-test or the one-way analysis of variance (ANOVA) test was used to compare means. Using the area under the receiver operating characteristic curve, model differentiation was evaluated (AUC). Z-test comparisons of AUC were carried out.

Results

Compared with the asthma/COPD group (asthma group + COPD group) or the COPD group, the levels of BUN and Cr were raised in the HF group, while there was no significant difference of the BUN/Cr ratio. Compared with those in the asthma group, the levels of BUN, Cr, and BUN/Cr ratio were significantly increased in the HF group (all p < 0.05), whereas no significant differences of BUN, Cr, and BUN/Cr ratio were found between asthma and COPD. The AUC in distinguishing HF from asthma/COPD were 0.736 and 0.751 for BUN and Cr, respectively, and no significant difference was observed between BUN and Cr. The cutoff values (specificity, sensitivity, and Youden index) in distinguishing between HF and asthma/COPD were 20.45 mg/dL (79.21%, 56.52%, and 0.357) for BUN and 0.782 mg/dL (72.28%, 68.12%, and 0.404) for Cr, respectively.

Conclusions

BUN and Cr showed accurate and reliable diagnostic values which could be potential biomarkers for differentiating HF from asthma and/or COPD.

Left Ventricular Diastolic Dysfunction and Progression of Chronic Kidney Disease: Analysis of KNOW-CKD Data

Background Few studies have examined the association between the early diastolic mitral inflow velocity/early diastolic mitral annulus velocity ratio (E/e') and chronic kidney disease progression. Methods and Results We reviewed data from 2238 patients with nondialysis chronic kidney disease from the KNOW-CKD (Korean Cohort Study for Outcome in Patients With Chronic Kidney Disease); data from 163 patients were excluded because of missing content. A >50% decrease in estimated glomerular filtration rate from baseline, doubling of serum creatinine, or dialysis initiation and/or kidney transplantation were considered renal events. At baseline, median (interquartile range) ejection fraction and E/e' were 64.0% (60.0%-68.0%) and 9.1 (7.4-11.9), respectively. Proportions of ejection fraction <50% and E/e' ≥15 were 1.3% and 9.6%, respectively. More than one quarter of patients (27.2%) had an estimated glomerular filtration rate <30 mL/min per 1.73 m². During the mean 59.1-month follow-up period, 724 patients (34.9%) experienced renal events. In multivariable Cox proportional hazard regression analysis, the hazard ratio with 95% CI per 1-unit increase in E/e' was 1.027 (1.005-1.050; P=0.016). Penalized spline curve analysis yielded a suggested threshold of E/e' for renal events of 12; in our data set, the proportion of E/e' ≥12 was 4.1%. Conclusions Increased E/e' was associated with an increased hazard of renal events, suggesting that diastolic heart dysfunction is a novel risk factor for chronic kidney disease progression.

Insights of Worsening Renal Function in Type 1 Cardiorenal Syndrome: From the Pathogenesis, Biomarkers to Treatment

Type-1 cardiorenal syndrome refers to acute kidney injury induced by acute worsening cardiac function. Worsening renal function is a strong and independent predictive factor for poor prognosis. Currently, several problems of the type-1 cardiorenal syndrome have not been fully elucidated. The pathogenesis mechanism of renal dysfunction is unclear. Besides, the diagnostic efficiency, sensitivity, and specificity of the existing biomarkers are doubtful. Furthermore, the renal safety of the therapeutic strategies for acute heart failure (AHF) is still ambiguous. Based on these issues, we systematically summarized and depicted the research actualities and predicaments of the pathogenesis, diagnostic markers, and therapeutic strategies of worsening renal function in type-1 cardiorenal syndrome.

Cardiorenal interaction and heart failure outcomes. A role for insulin-like growth factor binding protein 2?

INTRODUCTION AND OBJECTIVES

Preliminary results suggest that high circulating insulin-like growth factor binding protein 2 (IGFBP2) levels are associated with mortality risk in heart failure (HF) patients. As IGFBP2 levels are increased in patients with chronic kidney disease (CKD), which is associated with a higher mortality risk in HF patients, we examined whether IGFBP2 is associated with CKD in HF patients, and whether CKD modifies the prognostic value of this protein in HF patients.

METHODS

HF patients (n=686, mean age 66.6 years, 32.7% women) were enrolled and followed up for a median of 3.5 (min-max range: 0.1-6) years. Patients were classified as having CKD with decreased estimated glomerular filtration rate (eGFR <60mL/min/1.73 m²) or as having CKD with nondecreased eGFR (≥ 60mL/min/1.73 m²). Serum IGFBP2 was detected by ELISA.

RESULTS

IGFBP2 was increased (P <.001) in CKD patients with decreased eGFR (n=290, 42.3%) compared with patients with nondecreased eGFR. IGFBP2 was directly associated with NT-proBNP (P <.001) and inversely associated with eGFR (P <.001), with both associations being independent of confounding factors. IGFBP2 was directly and independently associated with cardiovascular and all-cause death (P <.001) in the whole group of patients, but showed a stronger association with cardiovascular death in CKD patients with decreased eGFR (P for interaction <.05), improving risk prediction in these patients over clinically relevant risk factors.

CONCLUSIONS

Serum IGFBP2 is associated with impaired renal function and prognosticates cardiovascular death in patients with HF and CKD with decreased eGFR. Thus, there is an effect modification of CKD on circulating IGFBP2 and on its association with cardiovascular mortality in HF patients.

Cystatin C for predicting all-cause mortality and rehospitalization in patients with heart failure: a meta-analysis

Circulating cystatin C (cys-C/CYC) has been identified as an independent predictor of all-cause mortality in patients with coronary artery disease and the general population. This meta-analysis aimed to systematically evaluate the association between elevated cys-C level and all-cause mortality and rehospitalization risk amongst patients with heart failure (HF). PubMed and Embase databases were searched until December 2017. All prospective observational studies that reported a multivariate-adjusted risk estimate of all-cause mortality and/or rehospitalization for the highest compared with lowest cys-C level in HF patients were included. Ten prospective studies involving 3155 HF patients were included. Meta-analysis indicated that the highest compared with lowest cys-C level was associated with an increased risk of all-cause mortality (hazard ratio (HR): 2.33; 95% confidence intervals (CI): 1.67-3.27; I²  = 75.0%, P<0.001) and combination of mortality/rehospitalization (HR: 2.06; 95%CI: 1.58-2.69; I²  = 41.6%, P=0.181). Results of stratified analysis indicated that the all-cause mortality risk was consistently found in the follow-up duration, cys-C cut-off value or type of HF subgroup. Elevated cys-C level is possibly associated with an increased risk of all-cause mortality and rehospitalization in HF patients. This increased risk is probably independent of creatinine or estimated glomerular filtration rate (eGFR).

Association Between the Lipid Profile and Renal Dysfunction in the Heart Failure Patients

BACKGROUND/AIMS

In heart failure patients with high prevalence of chronic renal disease (CKD), hospitalization and mortality, whether the lipid profile was associated with renal dysfunction remained unknown. The present study intended to clarify the association between the lipid profile and renal dysfunction in the heart failure patients.

METHODS

336 hospitalized heart failure patients with left ventricle ejection fraction (LVEF) ≤45% and New York Heart Association (NYHA) class II-IV were enrolled. The estimated glomerular filtration rate (eGFR) < 90 mL/min·1.73 m2 was defined as renal dysfunction. The demographic, clinical data, blood samples and echocardiography were documented. The Pearson simple linear correlation was performed to evaluate the confounding factors correlated with eGFR. The significantly correlated factors were enrolled in Logistic regression as confounding factors to determine the association between the lipid profile and renal dysfunction in the heart failure patients.

RESULTS

182 patients (54.2%) had renal dysfunction and 154 patients (45.8%) did not have renal dysfunction. The waist circumference, platelet counts, platelet distribution width (PDW), high density lipoprotein-cholesterol (HDL-C), apolipoprotein A1 (apoA1), albumin and left ventricular ejection fraction (LVEF) are positively correlated with eGFR (all P< 0.05). Meanwhile, the age, mean platelet volume (MPV), neutrophilic granulocyte percentage (NEUT%), urea nitrogen (BUN), creatinine and total bilirubin (TBIL) are negatively correlated with eGFR (all P< 0.05). The total cholesterol (TC), triglyceride, low density lipoprotein-cholesterol (LDL-C) and apolipoprotein B (apoB) show no correlation with eGFR. After the adjustment of sex, hypertension, diabetes mellitus, age, waist circumference, platelet counts, MPV, PDW, NEUT%, TBIL, albumin and LVEF, HDL-C is the only lipid factor still significantly associated with renal dysfunction in hospitalized heart failure patients (OR=0.119, P=0.003).

CONCLUSION

Among the lipid profile of TC, triglyceride, LDL-C, HDL-C, apo A1 and apo B, the HDL-C is the only lipid factor significantly associated with renal dysfunction in hospitalized heart failure patients.

Demographical and clinicopathological characteristics in heart failure and outcome predictors: a prospective, observational study

AIMS

The aims of the study were to study the demographical and clinicopathological characteristics of patients presenting with heart failure and evaluate the 1 year outcomes and to identify risk predictors if any.

METHODS AND RESULTS

A prospective observational study was conducted in consecutive patients of systolic heart failure. The study was divided into two parts-an initial 6 month enrolment phase followed up for 1 year for major adverse cardiovascular events. All patients were treated according to the Institutional Heart Failure Protocol. Demographical and clinicopathophysiological characteristics were studied, and results were analysed. A total of 143 patients were enrolled. The mean age of subjects was 56.4 years with male subjects constituting almost two-thirds of the study population. The commonest aetiology of heart failure was ischemic with valvular heart disease being the commonest cause of non-ischemic heart failure. Bendopnea, a recently described symptom of heart failure, was found in a significant number of subjects. By univariate analysis, male sex (P = 0.042) and cardiomegaly (P = 0.035) were predictors of rehospitalization, whereas the univariate predictors of mortality were ischemic aetiology (P = 0.000), age > 50 years (P = 0.007), hypertension (P = 0.012), worsening NYHA class (P = 0.003), diabetes mellitus (P = 0.009), and hypokalaemia (P = 0.006). Multivariate analysis performed showed age > 50 years [P = 0.007; OR (CI) = 13.547 (2.034-90.238)], NYHA class [P = 0.002; OR (CI) = 32.300 (3.733-276.532)], and hypokalaemia [P = 0.031; OR (CI) = 7.524 (1.208-46.862)] as significant predictors of mortality during long-term follow-up.

CONCLUSIONS

The study will definitely help us to throw more light in identifying risk predictors of heart failure and help in improving clinical outcomes.

Involvement of Cyclic Guanosine Monophosphate-Dependent Protein Kinase I in Renal Antifibrotic Effects of Serelaxin

Introduction: Kidney fibrosis has shown to be ameliorated through the involvement of cyclic guanosine monophosphate (cGMP) and its dependent protein kinase I (cGKI). Serelaxin, the recombinant form of human relaxin-II, increases cGMP levels and has shown beneficial effects on kidney function in acute heart failure patients. Antifibrotic properties of serelaxin are supposed to be mediated via relaxin family peptide receptor 1 and subsequently enhanced nitric oxide/cGMP to inhibit transforming growth factor-β (TGF-β) signaling. This study examines the involvement of cGKI in the antifibrotic signaling of serelaxin.

Methods and Results: Kidney fibrosis was induced by unilateral ureteral obstruction in wildtype (WT) and cGKI knock-out (KO) mice. After 7 days, renal antifibrotic effects of serelaxin were assessed. Serelaxin treatment for 7 days significantly increased cGMP in the kidney of WT and cGKI-KO. In WT, renal fibrosis was reduced through decreased accumulation of collagen1A1, total collagen, and fibronectin. The profibrotic connective tissue growth factor as well as myofibroblast differentiation were reduced and matrix metalloproteinases-2 and -9 were positively modulated after treatment. Moreover, Smad2 as well as extracellular signal-regulated kinase 1 (ERK1) phosphorylation were decreased, whereas phosphodiesterase (PDE) 5a phosphorylation was increased. However, these effects were not observed in cGKI-KO.

Conclusion: Antifibrotic renal effects of serelaxin are mediated via cGMP/cGKI to inhibit Smad2- and ERK1-dependent TGF-β signaling and increased PDE5a phosphorylation.

Association between cardiac, renal, and hepatic biomarkers and outcomes in patients with acute heart failure

OBJECTIVES

Myocardial injury, worsening renal function, and hepatic impairment are independent risk factors for poor patient acute heart failure (AHF) outcomes. Biomarkers of organ damage may be useful in identifying patients at risk for poor outcomes. The objective of this analysis was to assess the relationship between abnormal AHF biomarkers and outcomes in AHF patients.

METHODS

AHF admissions (N = 104,794) data from the Cerner Health Facts® inpatient database were analyzed retrospectively. Multivariate predictive models determined the impact of biomarkers on mortality, readmission, length of stay (LOS), and cost from index admission through 180 days post discharge. Thirty and 60 day time windows are reported but 180 day results were consistent with 60 day outcomes. Biomarkers evaluated were aspartate transaminase (AST), estimated glomerular filtration rate (eGFR), high sensitivity cardiac troponin, bilirubin, alanine transaminase (ALT), sodium, high sensitivity C-reactive protein (hs-CRP), uric acid, B-type natriuretic peptide (BNP), NT-ProBNP, blood urea nitrogen (BUN), serum creatinine (SCr), and hemoglobin.

RESULTS

All biomarkers evaluated except hs-CRP, uric acid, and NT-ProBNP were significant (p < 0.0001) predictors of mortality at all timepoints; non-significance for these 3 biomarkers is likely due to low patient counts (1%-2%). Odds ratios for significant biomarkers of mortality ranged from 1.168-2.076 at index admission, 1.205-1.946 at 30 days post-discharge, and 1.233-1.991 at 60 days post-discharge. AST, eGFR, troponin, ALT, BNP, BUN, SCr, and hemoglobin were significant (p < 0.0001) predictors of readmission risk at all timepoints. AST, eGFR, troponin, bilirubin, BUN, SCr, and hemoglobin were significant (p < 0.0001) predictors of cumulative LOS at all timepoints. AST, eGFR, troponin, ALT, sodium, BUN, and hemoglogin were significant (p < 0.0001) cost predictors at 30 and 60 days post-discharge.

CONCLUSIONS

Renal function measures were associated with outcomes in patients hospitalized for AHF. Increased vigilance of renal biomarkers may be warranted to assess risk and promote proactive clinical management to improve outcomes.

Association between chronic kidney disease progression and cardiovascular disease: results from the CRIC Study

BACKGROUND AND AIMS

There is limited information on the risk of progression of chronic kidney disease (CKD) among individuals with CVD (cardiovascular disease). We studied the association between prevalent CVD and the risk of progression of CKD among persons enrolled in a long-term observational study.

METHODS

A prospective cohort study of 3,939 women and men with CKD enrolled in the chronic renal insufficiency cohort (CRIC) study between June 2003 and June 2008. Prevalent cardiovascular disease (myocardial infarction/revascularization, heart failure, stroke, and peripheral vascular disease) was determined by self-report at baseline. The primary outcome was a composite of either end-stage renal disease or a 50% decline in estimated glomerular filtration rate (eGFR) from baseline.

RESULTS

One-third (1,316 of 3,939, 33.4%) of the study participants reported a history of any cardiovascular disease, and 9.6% (n = 382) a history of heart failure at baseline. After a median follow up of 6.63 years, 1,028 patients experienced the primary outcome. The composite of any CVD at baseline was not independently associated with the primary outcome (Hazard Ratio 1.04 95% CI (0.91, 1.19)). However, a history of heart failure was independently associated with a 29% higher risk of the primary outcome (Hazard Ratio 1.29 95% CI (1.06, 1.57)). The relationship between heart failure and risk of CKD progression was consistent in subgroups defined by age, race, gender, baseline eGFR, and diabetes. Neither the composite measure of any CVD or heart failure was associated with the rate of decline in eGFR.

CONCLUSIONS

Self-reported heart failure was an independent risk factor for the development of the endpoint of ESRD or 50% decline in GFR in a cohort of patients with chronic kidney disease.

Myocardial infarction worsens glomerular injury and microalbuminuria in rats with pre-existing renal impairment accompanied by the activation of ER stress and inflammation

Deterioration of renal function occurs after chronic heart failure in approximately one-third of patients, particularly in those with pre-existing renal impairment such as diabetic nephropathy. Impaired renal function in these patients is always associated with a worse prognosis. However, the mechanisms underlying such deterioration of renal function are still largely unknown. In three separate protocols, we compared 1) sham operation (Ctr, n = 10) with surgically induced myocardial infarction (MI, n = 10); 2) unilateral nephrectomy (UNX, n = 10) with UNX + MI (n = 10); and 3) STZ-induced type 1 diabetes (DB, n = 10) with DB + MI (n = 10). The differences between combined injury models (UNX + MI, DB + MI) and simple MI were also examined. Renal remodeling, function, ER stress (CHOP and GRP78) and inflammation (infiltration of inflammatory cells, NF-κB p65) were evaluated 12 weeks after MI. In common SD rats, MI activated less glomerular ER stress and inflammation, resulting in a minor change of glomerular remodeling and microalbuminuria. However, MI significantly increased the glomerular expression of GRP78 and CHOP in UNX and DB rats. In addition, it also promoted the infiltration of CD4+ T cells, particularly inflammatory cytokine (IFN-γ, IL-17, IL-4)-producing CD4+ T cells, and the expression of NF-κB p65 in the glomeruli. By contrast, significant glomerular fibrosis, glomerulosclerosis, podocyte injury and microalbuminuria were found in rats with UNX + MI and DB + MI. MI significantly increased chronic glomerular injury and microalbuminuria at 12 weeks in rats with pre-existing renal impairment, i.e., UNX and DB, but not common SD rats. These changes were accompanied by increased glomerular ER stress and immune-associated inflammation.

The hemodynamic and nonhemodynamic crosstalk in cardiorenal syndrome type 1

The organ crosstalk can be defined as the complex biological communication and feedback between distant organs mediated via cellular, molecular, neural, endocrine and paracrine factors. In the normal state, this crosstalk helps to maintain homeostasis and optimal functioning of the human body. However, during disease states this very crosstalk can carry over the influence of the diseased organ to initiate and perpetuate structural and functional dysfunction in the other organs. Heart performance and kidney function are intimately interconnected, and the communication between these organs occurs through a variety of bidirectional pathways. The cardiorenal syndrome (CRS) is defined as a complex pathophysiological disorder of the heart and the kidneys whereby acute or chronic dysfunction in one organ may induce acute or chronic dysfunction in the other organ. In particular, CRS type 1 is characterized by a rapid worsening of the cardiac function leading to acute kidney injury. This clinical condition requires a more complex management given its more complicated hospital course and higher mortality. A lot of research has emerged in the last years trying to explain the pathophysiology of CRS type 1 which remains in part poorly understood. This review primarily focuses on the hemodynamic and nonhemodynamic mechanisms involved in this syndrome.

Worsening renal function in heart failure: the need for a consensus definition

Acute decompensated heart failure is a common cause of hospitalisation. This is a period of vulnerability both in altered pathophysiology and also the potential for iatrogenesis due to therapeutic interventions. Renal dysfunction is often associated with heart failure and portends adverse outcomes. Identifying heart failure patients at risk of renal dysfunction is important in preventing progression to chronic kidney disease or worsening renal function, informing adjustment to medication management and potentially preventing adverse events. However, there is no working or consensus definition in international heart failure management guidelines for worsening renal function. In addition, there appears to be no concordance or adaptation of chronic kidney disease guidelines by heart failure guideline development groups for the monitoring of chronic kidney disease in heart failure. Our aim is to encourage the debate for an agreed definition given the prognostic impact of worsening renal function in heart failure. We present the case for the uptake of the Acute Kidney Injury Network criteria for acute kidney injury with some minor alterations. This has the potential to inform study design and meta-analysis thereby building the knowledgebase for guideline development. Definition consensus supports data element, clinical registry and electronic algorithm innovation as instruments for quality improvement and clinical research for better patient outcomes. In addition, we recommend all community managed heart failure patients have their baseline renal function classified and routinely monitored in accordance with established renal guidelines to help identify those at increased risk for worsening renal function or progression to chronic kidney disease.

Efficacy and safety of high dose versus low dose furosemide with or without dopamine infusion: the Dopamine in Acute Decompensated Heart Failure II (DAD-HF II) trial

AIMS

The role of low-dose dopamine infusion in patients with acute decompensated heart failure (ADHF) remains controversial. We aim to evaluate the efficacy and safety of high- versus low-dose furosemide with or without low-dose dopamine infusion in this patient population.

METHODS AND RESULTS

161 ADHF patients (78 years; 46% female; ejection fraction 31%) were randomized to 8-hour continuous infusions of: a) high-dose furosemide (HDF, n=50, 20mg/h), b) low-dose furosemide and low-dose dopamine (LDFD, n=56, 5mg/h and 5 μg kg(-1)min(-1) respectively), or c) low-dose furosemide (LDF, n=55, furosemide 5mg/h). The main outcomes were 60-day and one-year all-cause mortality (ACM) and hospitalization for HF (HHF). Dyspnea relief (Borg index), worsening renal function (WRF, rise in serum creatinine (sCr) ≥ 0.3mg/dL), and length of stay (LOS) were also assessed. The urinary output at 2, 4, 6, 8, and 24h was not significantly different in the three groups. Neither the ACM at day 60 (4.0%, 7.1%, and 7.2%; P=0.74) or at one year (38.1%, 33.9% and 32.7%, P=0.84) nor the HHF at day 60 (22.0%, 21.4%, and 14.5%, P=0.55) or one year (60.0%, 50.0%, and 47%, P=0.40) differed between HDF, LDFD, and LDF groups, respectively. No differences in the Borg index or LOS were noted. WRF was higher in the HDF than in LDFD and LDF groups at day 1 (24% vs. 11% vs. 7%, P<0.0001) but not at sCr peak (44% vs. 38% vs. 29%, P=0.27). No significant differences in adverse events were noted.

CONCLUSIONS

In ADHF patients, there were no significant differences in the in-hospital and post-discharge outcomes between high- vs. low-dose furosemide infusion; the addition of low-dose dopamine infusion was not associated with any beneficial effects.