Kugasenanchettiar Abbeykeith, Vasanthan Kowshijan, Saha Arkaprabha, Lakra Oltiana
General Internal Medicine, Ealing Hospital, Southall, GBR.
General Internal Medicine, George Eliot Hospital, Nuneaton, GBR.
Cureus. 2025 Jul 29;17(7):e88953. doi: 10.7759/cureus.88953. eCollection 2025 Jul.
IV loop diuretics remain the cornerstone of treatment for acute decompensated heart failure (ADHF). Although previous meta-analyses have compared continuous infusion and intermittent bolus dosing of IV loop diuretics, their respective renal effects remain unclear. Given the prognostic significance of worsening renal function (WRF) or acute kidney injury in ADHF, evaluating the renal safety of different diuretic regimens is essential. We conducted a systematic search of the PubMed database and performed a meta-analysis of randomized controlled trials (RCTs) comparing both diuretic strategies. The primary outcome was WRF, while secondary outcomes included increases in serum creatinine (sCr), sCr levels at discharge, discharge blood urea nitrogen (BUN) levels, and length of hospitalization. A post hoc trial sequential analysis (TSA) was also conducted to assess the adequacy of the current pooled evidence. A total of 11 RCTs were included. There was no statistically significant difference in the incidence of WRF between continuous infusion and intermittent bolus dosing (RR 1.12; 95% CI, 0.86 to 1.48; I² = 0.00%). Similarly, no significant differences were found in secondary outcomes: increase in sCr (mean difference (MD) 0.24 mg/dL; 95% CI, -0.17 to 0.66 mg/dL; I² = 98.7%), sCr at discharge (MD 0.33 mg/dL; 95% CI, -0.13 to 0.80 mg/dL; I² = 69.6%), discharge BUN levels (MD 6.57 mg/dL; 95% CI, -7.93 to 21.80 mg/dL; I² = 78.7%), and length of hospitalization (MD -0.50 days; 95% CI, -2.75 to 1.76 days; I² = 93.0%). The post hoc TSA revealed that the current evidence base is underpowered and inconclusive. Limited heterogeneity (I² = 0%) was observed among studies reporting WRF, indicating consistency in this primary outcome. However, the high I² values and wide CIs in the secondary outcomes reflect imprecise effect estimates, thereby limiting the clinical certainty of these findings. The TSA calculated a required information size of 3,342 participants, whereas the accrued information size in this meta-analysis was only 693 participants. This discrepancy underscores the potential for a type II error and reinforces the conclusion that current evidence remains insufficient to draw definitive conclusions. Overall, continuous infusion of loop diuretics does not appear to provide a significant renal advantage over intermittent bolus administration. The substantial evidence gap highlights the need for larger, high-quality RCTs powered to detect clinically meaningful renal outcomes. This study represents the first meta-analysis to prioritize renal endpoints and incorporate TSA in comparing these two diuretic strategies.
静脉用袢利尿剂仍然是急性失代偿性心力衰竭（ADHF）治疗的基石。尽管之前的荟萃分析比较了静脉用袢利尿剂的持续输注和间歇推注给药方式，但其各自对肾脏的影响仍不明确。鉴于肾功能恶化（WRF）或急性肾损伤在ADHF中的预后意义，评估不同利尿剂方案的肾脏安全性至关重要。我们对PubMed数据库进行了系统检索，并对比较这两种利尿剂策略的随机对照试验（RCT）进行了荟萃分析。主要结局是WRF，次要结局包括血清肌酐（sCr）升高、出院时的sCr水平、出院时血尿素氮（BUN）水平以及住院时间。还进行了事后试验序贯分析（TSA）以评估当前汇总证据的充分性。共纳入11项RCT。持续输注和间歇推注给药在WRF发生率上无统计学显著差异（风险比[RR] 1.12；95%置信区间[CI]，0.86至1.48；I² = 0.00%）。同样，在次要结局方面未发现显著差异：sCr升高（平均差[MD] 0.24 mg/dL；95% CI，-0.17至0.66 mg/dL；I² = 98.7%）、出院时sCr（MD 0.33 mg/dL；95% CI，-0.13至0.80 mg/dL；I² = 69.6%）、出院时BUN水平（MD 6.57 mg/dL；95% CI，-7.93至21.80 mg/dL；I² = 78.7%）以及住院时间（MD -0.50天；95% CI，-2.75至1.76天；I² = 93.0%）。事后TSA显示，当前的证据基础效力不足且结论不明确。在报告WRF的研究中观察到有限的异质性（I² = 0%），表明这一主要结局具有一致性。然而，次要结局中高I²值和宽置信区间反映了效应估计不精确，从而限制了这些发现的临床确定性。TSA计算得出所需的信息规模为3342名参与者，而本荟萃分析中积累的信息规模仅为693名参与者。这种差异凸显了II类错误的可能性，并强化了当前证据仍不足以得出明确结论的结论。总体而言，与间歇推注给药相比，持续输注袢利尿剂似乎并未在肾脏方面提供显著优势。巨大的证据差距凸显了开展更大规模、高质量RCT以检测具有临床意义的肾脏结局的必要性。本研究是第一项将肾脏终点作为优先事项并纳入TSA来比较这两种利尿剂策略的荟萃分析。
