title: Short and long-term effects of continuous versus intermittent loop diuretics treatment in acute heart failure with renal dysfunction.
abstract: Intravenous loop diuretics are still the cornerstone of therapy in acute decompensated heart failure, however, the optimal dosage and administration strategies remain poorly defined particularly in patients with an associated renal dysfunction. This is a single-center, pilot, randomized trial involving patients with acute HF and renal dysfunction. Patients were assigned to receive continuous furosemide infusion (cIV) or bolus injections of furosemide (iIV). Primary end points were the evaluation of urine output volumes, renal function, and b-type natriuretic peptide (BNP) levels during treatment time. Secondary end point included: weight loss, length of hospitalization, differences in plasma electrolytes, need for additional treatment, and evaluation of cardiac events during follow-up period. 57 patients were included in the study. The cIV group showed an increase in urine output (2,505 ± 796 vs 2140 ± 468 ml/day, p < 0.04) and a more significant decrease of BNP levels in respect to the iIV group (679.6 ± 397 vs 949 ± 548 pg/ml, p < 0.04). We observed a significant increase in creatinine levels (1.78 ± 0.5 vs 1.41 ± 0.3 mg/dl, p < 0.01), and a reduction of the estimated glomerular filtration rate in cIV (44.8 ± 6.1 vs 46.7 ± 6.1 ml/min, p < 0.05). We observed a significant difference in eGFR (p = 0.01), creatinine (p = 0.02) and BNP levels (p = 0.03) from baseline to the end of treatment in both groups. A significant increase of in-hospital additional treatment as well as length of hospitalization was observed in cIV. Finally, cIV revealed a higher rate of adverse events during the follow-up period (p < 0.03). cIV appears to provide a more efficient diuresis and BNP level reduction during hospitalization, however, it was associated with increased rate of worsening renal function during hospitalization. cIV also appears related to a longer hospitalization and an increased number of adverse events during follow-up. For all of these reasons, a larger multi-center study is required to determine whether high-dose diuretics are responsible for worsening renal function and to define the best modality of administration.
authors.affiliation: Department of Medical, Surgical and Neuro Sciences, Internal Medicine, S Maria Alle Scotte Hospital University of Siena, Siena, Italy, palazzuoli2@unisi.it.
authors.forename: Alberto
authors.initials: A
authors.lastname: Palazzuoli
authors.forename: Marco
authors.initials: M
authors.lastname: Pellegrini
authors.forename: Beatrice
authors.initials: B
authors.lastname: Franci
authors.forename: Matteo
authors.initials: M
authors.lastname: Beltrami
authors.forename: Gaetano
authors.initials: G
authors.lastname: Ruocco
authors.forename: Stefano
authors.initials: S
authors.lastname: Gonnelli
authors.forename: Gianni D
authors.initials: GD
authors.lastname: Angelini
authors.forename: Ranuccio
authors.initials: R
authors.lastname: Nuti
mesh_terms: D000208:Acute Disease / Q000628:therapy; D061605:Administration, Intravenous; D000368:Aged; D004232:Diuretics / Q000009:adverse effects / Q000627:therapeutic use*; D005260:Female; D005665:Furosemide / Q000009:adverse effects / Q000627:therapeutic use; D006333:Heart Failure / Q000150:complications / Q000188:drug therapy*; D006801:Humans; D008297:Male; D008875:Middle Aged; D051437:Renal Insufficiency / Q000150:complications / Q000188:drug therapy; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D004232:Diuretics; D005665:Furosemide
references.citation: Am Heart J. 2008 Oct;156(4):662-73
references.pmid: 18926148
references.citation: Acute Card Care. 2007;9(4):207-13
references.pmid: 17891672
references.citation: J Card Fail. 2011 Dec;17(12):993-1000
references.pmid: 22123361
references.citation: Am J Cardiol. 2010 Jun 15;105(12):1794-7
references.pmid: 20538132
references.citation: J Am Coll Cardiol. 2005 Jun 21;45(12):1997-2003
references.pmid: 15963399
references.citation: Circulation. 2009 Apr 14;119(14):1977-2016
references.pmid: 19324967
references.citation: Am Heart J. 2010 Aug;160(2):264-271.e1
references.pmid: 20691831
references.citation: Am J Kidney Dis. 2010 Oct;56(4):759-73
references.pmid: 20557988
references.citation: JAMA. 2005 Feb 2;293(5):572-80
references.pmid: 15687312
references.citation: J Card Fail. 2006 Feb;12(1):e86-e103
references.pmid: 16500576
references.citation: Eur Heart J. 2005 Apr;26(7):644-9
references.pmid: 15734765
references.citation: Am Heart J. 2009 Sep;158(3):422-30
references.pmid: 19699866
references.citation: Am J Cardiol. 2006 Nov 15;98(10):1416-7
references.pmid: 17134642
references.citation: J Card Fail. 2010 Mar;16(3):188-93
references.pmid: 20206891
references.citation: Circ Heart Fail. 2014 Mar 1;7(2):261-70
references.pmid: 24379278
references.citation: N Engl J Med. 2011 Mar 3;364(9):797-805
references.pmid: 21366472
references.citation: Circ Heart Fail. 2012 Jan;5(1):54-62
references.pmid: 22167320
references.citation: Am Heart J. 2009 Sep;158(3):488-95
references.pmid: 19699875
references.citation: Ann Intern Med. 2006 Aug 15;145(4):247-54
references.pmid: 16908915
references.citation: Am Heart J. 2004 Feb;147(2):331-8
references.pmid: 14760333
references.citation: Crit Care. 2007;11(2):R31
references.pmid: 17331245
references.citation: Eur J Heart Fail. 2009 Sep;11(9):847-54
references.pmid: 19696057
references.citation: J Card Fail. 2003 Feb;9(1):13-25
references.pmid: 12612868
references.citation: Eur J Heart Fail. 2008 Feb;10(2):188-95
references.pmid: 18279773
references.citation: Am J Cardiol. 2006 Jun 15;97(12):1759-64
references.pmid: 16765130
references.citation: Circ Heart Fail. 2009 Jan;2(1):56-62
references.pmid: 19750134
references.citation: Am Heart J. 2012 Mar;163(3):407-14, 414.e1
references.pmid: 22424011
references.citation: Eur J Heart Fail. 2007 Oct;9(10):1064-9
references.pmid: 17719273
references.citation: J Am Coll Cardiol. 2009 Feb 17;53(7):557-573
references.pmid: 19215829