Renal safety of a natriuresis-guided diuretic strategy in hospitalised heart failure
S Singh, S Castro, M Elajami, J Callaghan, M Khan, M Boisjoli-Langlois, S Arora, J Radojevic, A Jaiswal, G SinghAbstract
Background/Introduction
Decongestion with loop diuretics is central to the management of hospitalised heart failure (HF), yet escalation of diuretic therapy is frequently limited by concern for acute kidney injury (AKI). Natriuresis-guided strategies use early urine sodium response to guide diuretic escalation, but real-world safety data remain limited.
Purpose
To assess renal safety outcomes with a natriuresis-guided diuretic protocol and compare outcomes between urine sodium goal achievers and non-achievers in hospitalised HF.
Methods
We conducted a retrospective analysis of consecutive HF admissions managed with a pharmacist-led, natriuresis-guided intravenous (IV) furosemide protocol at a tertiary care centre. IV furosemide was initiated as a one-time bolus at twice the home loop diuretic dose (or 40 mg IV if diuretic-naive), followed by twice-daily dosing. Spot urine sodium and urine creatinine were obtained 2 hours after dosing to estimate predicted urinary sodium output using a pre-specified equation. If predicted sodium output was ≥100 mmol, the furosemide dose was continued without repeat urine testing. If predicted sodium output was <100 mmol, the next dose was doubled (maximum 160 mg IV twice daily), with repeat urine indices after each dose change. Patients requiring doses above this threshold were removed from the protocol and managed with infusion or alternative strategies. Outcomes included AKI defined by Kidney Disease: Improving Global Outcomes (KDIGO) criteria, change in creatinine during hospitalisation, escalation to intensive care unit (ICU) within 48 hours of protocol initiation, and in-hospital mortality. Length of stay (LOS) and 30-day all-cause readmission were assessed as secondary outcomes. Data are reported descriptively.
Results
Among 162 HF admissions treated with the protocol, AKI occurred in 25 (15.4%) of patients (Stage 1: n = 24; Stage 2: n = 0; Stage 3: n = 1). Patients achieving the protocol natriuresis goal had a lower AKI incidence compared to non-achievers (8.1% vs 19.7%). ICU transfer within 48 hours occurred in 1.2% of patients overall and was not observed among goal achievers. In-hospital mortality occurred in 1.2% of patients and was confined to non-achievers. Changes in creatinine during hospitalisation were modest and comparable between groups. Median LOS was similar between goal achievers and non-achievers (6 vs 5 days), and 30-day readmission rates were comparable.
Conclusion(s)
In hospitalized HF, a natriuresis-guided diuretic strategy was associated with a low overall incidence of AKI and rare severe AKI, with no observed signal of excess ICU transfer or in-hospital mortality. Achievement of natriuretic goals was associated with numerically lower AKI rates without longer hospital stay. These findings support the renal safety of natriuresis-guided decongestion in routine clinical practice.Protocol overview and outcomesFor image description, please refer to the figure legend and surrounding text.