Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut.
Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut.
JACC Heart Fail. 2019 May;7(5):383-391. doi: 10.1016/j.jchf.2019.01.007.
This study sought to describe sodium excretion in acute decompensated heart failure (ADHF) clearly and to evaluate the prognostic ability of urinary sodium and fluid-based metrics.
Sodium retention drives volume overload, with fluid retention largely a passive, secondary phenomenon. However, parameters (urine output, body weight) used to monitor therapy in ADHF measure fluid rather than sodium balance. Thus, the accuracy of fluid-based metrics hinges on the contested assumption that urinary sodium content is consistent.
Patients enrolled in the ROSE-AHF (Renal Optimization Strategies Evaluation-Acute Heart Failure) trial with 24-h sodium excretion available were studied (n = 316). Patients received protocol-driven high-dose loop diuretic therapy.
Sodium excretion through the first 24 h was highly variable (range 0.12 to 19.8 g; median 3.63 g, interquartile range: 1.85 to 6.02 g) and was not correlated with diuretic agent dose (r = 0.06; p = 0.27). Greater sodium excretion was associated with reduced mortality in a univariate model (hazard ratio: 0.80 per doubling of sodium excretion; 95% confidence interval: 0.66 to 0.95; p = 0.01), whereas gross urine output (p = 0.43), net fluid balance (p = 0.87), and weight change (p = 0.11) were not. Sodium excretion of less than the prescribed dietary sodium intake (2 g), even in the setting of a negative net fluid balance, portended a worse prognosis (hazard ratio: 2.02; 95% confidence interval: 1.17 to 3.46; p = 0.01).
In patients hospitalized with ADHF who were receiving high-dose loop diuretic agents, sodium concentration and excretion were highly variable. Sodium excretion was strongly associated with 6-month mortality, whereas traditional fluid-based metrics were not. Poor sodium excretion, even in the context of fluid loss, portends a worse prognosis.
本研究旨在清楚地描述急性失代偿性心力衰竭（ADHF）中的钠排泄情况，并评估尿钠和液体相关指标的预后能力。
钠潴留导致容量超负荷，而液体潴留主要是一种被动的、继发的现象。然而，用于监测 ADHF 治疗的参数（尿量、体重）测量的是液体而不是钠平衡。因此，液体相关指标的准确性取决于一个有争议的假设，即尿钠含量是一致的。
对 ROSE-AHF（肾脏优化策略评估-急性心力衰竭）试验中可用 24 小时尿钠排泄数据的患者进行研究（n=316）。患者接受了方案驱动的大剂量袢利尿剂治疗。
第 1 个 24 小时内的钠排泄量变化很大（范围为 0.12 至 19.8 g；中位数为 3.63 g，四分位间距：1.85 至 6.02 g），且与利尿剂剂量无关（r=0.06；p=0.27）。在单变量模型中，更大的钠排泄量与死亡率降低相关（风险比：钠排泄量每增加一倍，风险降低 0.80；95%置信区间：0.66 至 0.95；p=0.01），而总尿量（p=0.43）、净液体平衡（p=0.87）和体重变化（p=0.11）则不然。即使在净液体负平衡的情况下，摄入的膳食钠量低于规定量（2 g），也预示着预后更差（风险比：2.02；95%置信区间：1.17 至 3.46；p=0.01）。
在接受大剂量袢利尿剂治疗的 ADHF 住院患者中，钠浓度和排泄量变化很大。钠排泄量与 6 个月死亡率密切相关，而传统的液体相关指标则不然。即使在液体丢失的情况下，钠排泄量较差也预示着预后更差。
