title: Urinary composition during decongestive treatment in heart failure with reduced ejection fraction.
abstract: BACKGROUND
  The urinary composition, including sodium (Na(+)) and chloride (Cl(-)) concentrations, might provide useful information in addition to urine output during decongestive treatment in heart failure.
  
  
  RESULTS
  Consecutive patients with heart failure (n=61), ejection fraction ≤45%, worsening symptoms, and scheduled treatment with intravenous loop diuretics were included. Patients received protocol-driven therapy until complete decongestion, assessed clinically and by echocardiography. Three consecutive 24-hour urinary collections were performed. With 2 mg (1-4 mg), 1 mg (0-2 mg), and 1 mg (0-1 mg) bumetanide administered in bolus during consecutive 24-hour intervals, in addition to combinational diuretic therapy in ≈70% and both oral spironolactone and vasodilators in ≈90%, euvolemia was reached, often within 24 hours. Urine output was higher during the first when compared with the second or third 24-hour interval (2700 versus 1550 or 1375 mL, respectively; P<0.001), but this was no longer significant after correction for diuretic dose (P=0.263), indicating preserved diuretic efficiency during the study. In contrast, urinary Na(+) and Cl(-) excretion both decreased significantly, even after correction for diuretic dose (P=0.040 and 0.004, respectively), leading to decreasing urinary concentrations with progressive decongestion. After reaching euvolemia, lower urinary Na(+)/Cr and Cl(-)/Cr ratios were both associated with urine output ≤1500 mL (area under the curve, 0.830 and 0.826, respectively; P<0.001 for both), in contrast to plasma N-terminal pro-B-type natriuretic peptide levels that were not (area under the curve, 0.515; P=0.735) CONCLUSIONS: The urinary composition during progressive decongestion in heart failure with reduced ejection fraction is characterized by a drop in urinary Na(+) and Cl(-) concentrations. The urinary Na(+)/Cr or Cl(-)/Cr ratio might provide insightful information to titrate diuretic therapy.
authors.affiliation: From the Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (F.H.V., P.N., M.D., W.M.); Doctoral School for Medicine and Life Sciences (F.H.V., P.N.) and Biomedical Research Institute, Faculty of Medicine and Life Sciences (J.P., W.M.), Hasselt University, Diepenbeek, Belgium; Department of Laboratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium (J.P.); and Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH (W.H.W.T.).
authors.forename: Frederik H
authors.initials: FH
authors.lastname: Verbrugge
authors.affiliation: From the Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (F.H.V., P.N., M.D., W.M.); Doctoral School for Medicine and Life Sciences (F.H.V., P.N.) and Biomedical Research Institute, Faculty of Medicine and Life Sciences (J.P., W.M.), Hasselt University, Diepenbeek, Belgium; Department of Laboratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium (J.P.); and Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH (W.H.W.T.).
authors.forename: Petra
authors.initials: P
authors.lastname: Nijst
authors.affiliation: From the Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (F.H.V., P.N., M.D., W.M.); Doctoral School for Medicine and Life Sciences (F.H.V., P.N.) and Biomedical Research Institute, Faculty of Medicine and Life Sciences (J.P., W.M.), Hasselt University, Diepenbeek, Belgium; Department of Laboratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium (J.P.); and Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH (W.H.W.T.).
authors.forename: Matthias
authors.initials: M
authors.lastname: Dupont
authors.affiliation: From the Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (F.H.V., P.N., M.D., W.M.); Doctoral School for Medicine and Life Sciences (F.H.V., P.N.) and Biomedical Research Institute, Faculty of Medicine and Life Sciences (J.P., W.M.), Hasselt University, Diepenbeek, Belgium; Department of Laboratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium (J.P.); and Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH (W.H.W.T.).
authors.forename: Joris
authors.initials: J
authors.lastname: Penders
authors.affiliation: From the Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (F.H.V., P.N., M.D., W.M.); Doctoral School for Medicine and Life Sciences (F.H.V., P.N.) and Biomedical Research Institute, Faculty of Medicine and Life Sciences (J.P., W.M.), Hasselt University, Diepenbeek, Belgium; Department of Laboratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium (J.P.); and Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH (W.H.W.T.).
authors.forename: W H Wilson
authors.initials: WH
authors.lastname: Tang
authors.affiliation: From the Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium (F.H.V., P.N., M.D., W.M.); Doctoral School for Medicine and Life Sciences (F.H.V., P.N.) and Biomedical Research Institute, Faculty of Medicine and Life Sciences (J.P., W.M.), Hasselt University, Diepenbeek, Belgium; Department of Laboratory Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium (J.P.); and Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, OH (W.H.W.T.). wilfried.mullens@zol.be.
authors.forename: Wilfried
authors.initials: W
authors.lastname: Mullens
mesh_terms: D000284:Administration, Oral; D000368:Aged; D015415:Biomarkers / Q000652:urine; D002034:Bumetanide / Q000008:administration & dosage; D002712:Chlorides / Q000652:urine*; D004232:Diuretics / Q000008:administration & dosage*; D004305:Dose-Response Relationship, Drug; D004359:Drug Therapy, Combination; D004452:Echocardiography; D005260:Female; D006333:Heart Failure / Q000188:drug therapy / Q000503:physiopathology / Q000652:urine*; D006352:Heart Ventricles / Q000000981:diagnostic imaging / Q000503:physiopathology*; D006801:Humans; D007275:Injections, Intravenous; D008297:Male; D012964:Sodium / Q000652:urine*; D013148:Spironolactone / Q000008:administration & dosage; D013318:Stroke Volume / Q000502:physiology*; D016896:Treatment Outcome; D016482:Urinalysis; D014554:Urination / Q000187:drug effects / Q000502:physiology; D014665:Vasodilator Agents / Q000008:administration & dosage*
chemical_list: D015415:Biomarkers; D002712:Chlorides; D004232:Diuretics; D014665:Vasodilator Agents; D002034:Bumetanide; D013148:Spironolactone; D012964:Sodium
keywords: sodium; systolic heart failure; urea; urine