University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands.
Eur J Heart Fail. 2024 Jun;26(6):1347-1357. doi: 10.1002/ejhf.3228. Epub 2024 May 12.
In a randomized controlled trial, we recently showed that a natriuresis-guided diuretic approach improved natriuresis and diuresis in patients with acute heart failure (HF). In this pre-specified analysis, we investigated the association between (worsening) renal function, outcomes and the effect of intensive natriuresis-guided loop diuretic therapy as compared with standard of care.
The Pragmatic Urinary Sodium-based algoritHm in Acute Heart Failure (PUSH-AHF) trial randomized patients to natriuresis-guided diuretic therapy or standard of care. Serum creatinine and estimated glomerular filtration rate (eGFR) were assessed at fixed timepoints, and worsening renal function (WRF) was assessed at 72 h. The primary outcome was the interaction between randomized treatment allocation, baseline eGFR and the dual primary outcome of PUSH-AHF: total natriuresis at 24 h and time to all-cause mortality or HF rehospitalization at 180 days. In 309 patients, median baseline eGFR was 53 (35-73) ml/min/1.73 m, and 58% had eGFR <60 ml/min/1.73 m. Baseline eGFR did not significantly modify the treatment effect of natriuresis-guided diuretic therapy on natriuresis at 24 h (p for interaction = 0.730). However, baseline eGFR significantly modified the effect on all-cause mortality and HF rehospitalization (p for interaction = 0.017): the risk of this second primary outcome was lower in patients with lower eGFR who were randomized to the natriuresis-guided group. In the natriuresis-guided arm, eGFR decreased more (-11.0 vs. -6.91 ml/min/1.73 m; p = 0.002) during the first 3 days, but this effect was attenuated at discharge (-10.3 vs. -8.69 ml/min/1.73 m; p = 0.38). WRF was more frequently observed in patients randomized to natriuresis-guided treatment, but was not associated with worse clinical outcomes.
Natriuresis-guided diuretic treatment improved diuresis and natriuresis irrespective of baseline eGFR and occurrence of WRF, was effective even in patients with low eGFR, and the observed effect on eGFR was transient and not associated with worse clinical outcomes.
在一项随机对照试验中，我们最近表明，利尿作用指导下的利钠治疗可改善急性心力衰竭（HF）患者的利钠和利尿作用。在这项预先指定的分析中，我们研究了肾功能恶化（WRF）与结局之间的关联，以及与标准治疗相比，强化利尿作用指导下的袢利尿剂治疗的效果。
实用尿钠算法在急性心力衰竭中的应用（PUSH-AHF）试验将患者随机分配至利尿作用指导治疗或标准治疗。在固定时间点评估血清肌酐和估算肾小球滤过率（eGFR），并在 72 小时评估肾功能恶化（WRF）。主要结局是随机治疗分配、基线 eGFR 与 PUSH-AHF 的双重主要结局之间的交互作用：24 小时总利钠作用和至全因死亡率或 180 天内 HF 再入院的时间。在 309 例患者中，中位基线 eGFR 为 53（35-73）ml/min/1.73m2，58%的患者 eGFR＜60ml/min/1.73m2。基线 eGFR 并未显著改变利尿作用指导治疗对 24 小时利钠作用的治疗效果（交互作用 p 值=0.730）。然而，基线 eGFR 显著改变了全因死亡率和 HF 再入院的影响（交互作用 p 值=0.017）：在随机分组至利尿作用指导组的 eGFR 较低的患者中，这一二级主要结局的风险更低。在利尿作用指导组中，eGFR 在最初 3 天内下降更多（-11.0 与-6.91ml/min/1.73m2；p=0.002），但在出院时这一效应减弱（-10.3 与-8.69ml/min/1.73m2；p=0.38）。在随机接受利尿作用指导治疗的患者中更频繁地观察到 WRF，但与临床结局恶化无关。
利尿作用指导的利尿治疗改善了利尿和利钠作用，与基线 eGFR 无关，与 WRF 的发生无关，即使在 eGFR 较低的患者中也有效，并且观察到的 eGFR 效应是短暂的，与临床结局恶化无关。
