Meekers Evelyne, Dauw Jeroen, Ter Maaten Jozine M, Martens Pieter, Nijst Petra, Verbrugge Frederik H, Van Es Marnicq, Erzeel Jonas, Damman Kevin, Trullàs Joan Carles, Dupont Matthias, Mullens Wilfried
Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium.
Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium.
Eur J Heart Fail. 2025 Jun;27(6):940-949. doi: 10.1002/ejhf.3632. Epub 2025 Feb 27.
In patients with heart failure, neurohumoral activation leads to increased renal sodium avidity across the entire renal tubules, resulting in a positive sodium and water balance, leading to decompensated heart failure requiring intravenous diuretics. As the dose of diuretic therapy required to achieve euvolaemia is difficult to estimate due to considerable intra- and interindividual differences, the European Society of Cardiology recommends assessment of the diuretic response within hours either via evaluation of the urinary sodium concentration or via urinary volume after initial diuretic administration. All diuretic agents enhance sodium excretion to a different extent depending on their side of action across the renal tubules, and renal adaptation mechanisms due to neurohumoral stimulation. Impaired sodium excretion, even in the presence of fluid loss, is associated with worse clinical outcomes. Therefore, assessing urinary sodium excretion is considered a good and direct marker of the diuretic efficacy. Such natriuresis-guided protocols have been tested prospectively by the Pragmatic Urinary Sodium-based algoritHm in Acute Heart Failure and the Efficacy of a Standardized Diuretic Protocol in Acute Heart Failure study, both demonstrating increased natriuresis and diuresis. Moreover, the Readily Available Urinary Sodium Analysis in Patients with Acute Decompensated Heart Failure study has demonstrated that a nurse-led natriuresis-guided protocol is feasible through the use of a point-of-care urinary sodium sensor, allowing an immediately readable urinary sodium result, enabling fast changes in diuretic therapy. This review summaries the rationale, current evidence and gaps supporting the role of urinary sodium concentration in patients with acute decompensated heart failure.
在心力衰竭患者中，神经体液激活导致整个肾小管对钠的重吸收增加，从而导致钠和水平衡呈正值，进而导致失代偿性心力衰竭，需要静脉使用利尿剂。由于个体内和个体间存在相当大的差异，难以估计达到血容量正常所需的利尿剂治疗剂量，因此欧洲心脏病学会建议在首次使用利尿剂后的数小时内，通过评估尿钠浓度或尿量来评估利尿剂反应。所有利尿剂根据其在肾小管的作用部位以及神经体液刺激引起的肾脏适应机制，在不同程度上增强钠排泄。即使存在液体丢失，钠排泄受损也与更差的临床结局相关。因此，评估尿钠排泄被认为是利尿剂疗效的一个良好且直接的指标。急性心力衰竭实用尿钠算法和急性心力衰竭标准化利尿剂方案疗效研究均对这种以尿钠排泄为导向的方案进行了前瞻性测试，两者均显示尿钠排泄和利尿增加。此外，急性失代偿性心力衰竭患者即时可用尿钠分析研究表明，通过使用床旁尿钠传感器，由护士主导的以尿钠排泄为导向的方案是可行的，该传感器可提供即时可读的尿钠结果，从而能够快速调整利尿剂治疗。本综述总结了支持尿钠浓度在急性失代偿性心力衰竭患者中作用的基本原理、当前证据和差距。
