Hospital Moinhos de Vento (HMV), R. Ramiro Barcelos, 910, 91787070, Porto Alegre, RS, Brazil.
Quality and Management in Research, Diretoria de Pesquisa, Hospital de Clínicas de Porto Alegre, Brazil; Faculty, Graduate Program in Cardiology, School of Medicine, Universidade Federal do Rio Grande do Sul, Brazil.
Clin Nutr ESPEN. 2022 Jun;49:129-137. doi: 10.1016/j.clnesp.2022.03.032. Epub 2022 Apr 6.
Heart failure (HF) is a growing problem for healthcare systems worldwide. Sodium and fluid restriction are non-pharmacological treatments recommended for patients with HF by several guidelines over the years, even without consensus.
To evaluate the effects of sodium and fluid restriction in patients with HF.
We searched MEDLINE, Embase, and Cochrane CENTRAL databases up to June 2020 and screened the reference lists of relevant articles. We included randomized controlled trials evaluating sodium and/or fluid restriction in patients with HF. We assessed three independent comparisons: (a) sodium restriction versus control; (b) fluid restriction versus control; and (c) sodium and fluid restriction versus control. Main outcomes of interest were all-cause mortality and hospitalization. Two independent reviewers selected studies and extracted data. We pooled the results using random-effects meta-analysis. We used the RoB 2.0 and the GRADE framework to assess risk of bias and quality of evidence.
We included 16 studies totaling 3545 patients in our meta-analysis. Daily sodium intake was 1.5-2.4 g for the intervention group and >2.7 g for the control group, and daily fluid intake was 0.8-1.5 L for the intervention group and free oral fluid intake for the control group. Sodium restriction increased mortality (relative risk 1.92, 95% confidence interval 1.51 to 2.45, moderate quality of evidence) and hospitalization (relative risk 1.63, 1.11 to 2.40, low quality of evidence). Fluid restriction reduced mortality (relative risk 0.32, 0.13 to 0.82, low quality of evidence) and hospitalization (relative risk 0.46, 0.27 to 0.77, n = 331, low quality of evidence). The combination of sodium and fluid restriction did not significantly affect the risk of mortality (relative risk 0.92, 0.49 to 1.73, low quality of evidence) or the risk of hospitalization (relative risk 0.94, 0.75 to 1.19, low quality of evidence).
The combination of sodium and fluid restriction in clinical trials resulted in a null effect although results in the opposite direction were observed for each intervention independently. Combined sodium and fluid restriction are usually recommended for patients with HF. Our findings of sodium restriction harm, risk of mortality and hospitalization are consistent with publications from several clinical trial and physiologic explanations. A well-designed clinical trial nested by an implementation study is urgent for definitive sodium range recommendation, specially considering the change of currently guidelines, pushing up the cut-off of sodium restriction range.
心力衰竭（HF）是全球医疗系统面临的一个日益严重的问题。多年来，几项指南都推荐将钠和液体限制作为 HF 患者的非药物治疗方法，尽管尚未达成共识。
评估钠和液体限制对 HF 患者的影响。
我们检索了 MEDLINE、Embase 和 Cochrane CENTRAL 数据库，检索时间截至 2020 年 6 月，并筛选了相关文章的参考文献列表。我们纳入了评估 HF 患者钠和/或液体限制的随机对照试验。我们评估了三个独立的比较：（a）钠限制与对照组；（b）液体限制与对照组；和（c）钠和液体限制与对照组。主要观察终点是全因死亡率和住院率。两名独立的审查员选择研究并提取数据。我们使用随机效应荟萃分析汇总结果。我们使用 RoB 2.0 和 GRADE 框架评估偏倚风险和证据质量。
我们的荟萃分析纳入了 16 项研究，共 3545 名患者。干预组的每日钠摄入量为 1.5-2.4 g，对照组为 >2.7 g，干预组的每日液体摄入量为 0.8-1.5 L，对照组为自由口服液体摄入。钠限制增加了死亡率（相对风险 1.92，95%置信区间 1.51 至 2.45，中等质量证据）和住院率（相对风险 1.63，1.11 至 2.40，低质量证据）。液体限制降低了死亡率（相对风险 0.32，0.13 至 0.82，低质量证据）和住院率（相对风险 0.46，0.27 至 0.77，n=331，低质量证据）。钠和液体限制的联合应用并未显著影响死亡率风险（相对风险 0.92，0.49 至 1.73，低质量证据）或住院率风险（相对风险 0.94，0.75 至 1.19，低质量证据）。
尽管每项干预措施的结果都指向相反的方向，但临床试验中钠和液体限制的联合应用并未产生显著效果。通常建议 HF 患者联合使用钠和液体限制。我们关于钠限制危害、死亡率和住院率的发现与几项临床试验和生理解释的结果一致。迫切需要一项嵌套实施研究的精心设计的临床试验来确定钠的推荐范围，特别是考虑到目前指南的变化，将钠限制范围的截止值推高。
