title: Continuous versus bolus intermittent loop diuretic infusion in acutely decompensated heart failure: a prospective randomized trial.
abstract: BACKGROUND
  Intravenous loop diuretics are a cornerstone of therapy in acutely decompensated heart failure (ADHF). We sought to determine if there are any differences in clinical outcomes between intravenous bolus and continuous infusion of loop diuretics.
  
  
  METHODS
  Subjects with ADHF within 12 hours of hospital admission were randomly assigned to continuous infusion or twice daily bolus therapy with furosemide. There were three co-primary endpoints assessed from admission to discharge: the mean paired changes in serum creatinine, estimated glomerular filtration rate (eGFR), and reduction in B-type natriuretic peptide (BNP). Secondary endpoints included the rate of acute kidney injury (AKI), change in body weight and six months follow-up evaluation after discharge.
  
  
  RESULTS
  A total of 43 received a continuous infusion and 39 were assigned to bolus treatment. At discharge, the mean change in serum creatinine was higher (+0.8 ± 0.4 versus -0.8 ± 0.3 mg/dl P <0.01), and eGFR was lower (-9 ± 7 versus +5 ± 6 ml/min/1.73 m(2) P <0.05) in the continuous arm. There was no significant difference in the degree of weight loss (-4.1 ± 1.9 versus -3.5 ± 2.4 kg P = 0.23). The continuous infusion arm had a greater reduction in BNP over the hospital course, (-576 ± 655 versus -181 ± 527 pg/ml P = 0.02). The rates of AKI were comparable (22% and 15% P = 0.3) between the two groups. There was more frequent use of hypertonic saline solutions for hyponatremia (33% versus 18% P <0.01), intravenous dopamine infusions (35% versus 23% P = 0.02), and the hospital length of stay was longer in the continuous infusion group (14. 3 ± 5 versus 11.5 ± 4 days, P <0.03). At 6 months there were higher rates of re-admission or death in the continuous infusion group, 58% versus 23%, (P = 0.001) and this mode of treatment independently associated with this outcome after adjusting for baseline and intermediate variables (adjusted hazard ratio = 2.57, 95% confidence interval, 1.01 to 6.58 P = 0.04).
  
  
  CONCLUSIONS
  In the setting of ADHF, continuous infusion of loop diuretics resulted in greater reductions in BNP from admission to discharge. However, this appeared to occur at the consequence of worsened renal filtration function, use of additional treatment, and higher rates of rehospitalization or death at six months.
  
  
  BACKGROUND
  ClinicalTrials.gov NCT01441245. Registered 23 September 2011.
authors: Alberto
authors: A
authors: Palazzuoli
authors: Marco
authors: M
authors: Pellegrini
authors: Gaetano
authors: G
authors: Ruocco
authors: Giuseppe
authors: G
authors: Martini
authors: Beatrice
authors: B
authors: Franci
authors: Maria Stella
authors: MS
authors: Campagna
authors: Marilyn
authors: M
authors: Gilleman
authors: Ranuccio
authors: R
authors: Nuti
authors: Peter A
authors: PA
authors: McCullough
authors: Claudio
authors: C
authors: Ronco
mesh_terms: D058186:Acute Kidney Injury / Q000209:etiology; D000368:Aged; D000369:Aged, 80 and over; D003404:Creatinine / Q000097:blood; D004232:Diuretics / Q000008:administration & dosage* / Q000009:adverse effects; D004311:Double-Blind Method; D005260:Female; D005665:Furosemide / Q000008:administration & dosage* / Q000009:adverse effects; D005919:Glomerular Filtration Rate; D006333:Heart Failure / Q000150:complications / Q000188:drug therapy* / Q000503:physiopathology; D006801:Humans; D007010:Hyponatremia / Q000209:etiology / Q000628:therapy; D007262:Infusions, Intravenous; D007275:Injections, Intravenous; D007902:Length of Stay; D008297:Male; D020097:Natriuretic Peptide, Brain / Q000097:blood; D011446:Prospective Studies; D014556:Urine; D015431:Weight Loss
chemical_list: D004232:Diuretics; D020097:Natriuretic Peptide, Brain; D005665:Furosemide; D003404:Creatinine