Author + information
- Kavita Sharma, MD∗ (, )
- Joban Vaishnav, MD and
- Stuart D. Russell, MD
- ↵∗The Johns Hopkins Hospital, 600 North Wolfe Street, Carnegie 568C, Baltimore, Maryland 21287
We thank our colleagues for their interest in our clinical study of diuretic strategy and low-dose dopamine in the treatment of hospitalized heart failure with preserved ejection fraction patients, and for raising a number of important questions regarding the study design and analysis (1). We wholeheartedly agree that total diuretic dose administered is an important consideration in comparing incidence of worsening renal function between a continuous infusion (CF) strategy and an intermittent bolus (IF) strategy. Unfortunately, dose administration data were unavailable for more than one-half of the patients randomized in the study at time of data analysis due to a transition in the inpatient electronic medical record system at our institution during the study enrollment period. This is a significant limitation that we acknowledge in our study.
To clarify the treatment guidelines during the study period, the enrolled patients’ primary teams were instructed to treat for acute heart failure per standard of care and with the suggested goal of a net negative fluid balance of at least 1 liter daily. During the 72-h study period, the primary teams were instructed to use intravenous furosemide only. In the DOSE (Diuretic Optimization Strategies Evaluation) trial (2), the high-dose diuretic arm, compared with the low-dose arm, had significantly greater worsening renal function in addition to greater net fluid loss. Though we do not have total diuretic dose available for all patients, we did not see a significant difference in fluid loss between the IF and CF groups, which we might have expected were there a large dosage discrepancy.
Our initial hypothesis was that the CF strategy would mitigate fluctuations in preload and renal perfusion, resulting in less worsening renal function. We appreciate our colleagues’ point regarding the unexpected adverse renal signal in the CF arm compared with the IF arm. We did observe a trend toward lower blood pressure with CF strategy and can only speculate that relative renal hypoperfusion may have played a role in the development of worsening renal function.
Finally, we agree that the long-term implications of worsening renal function in HF are unclear, with increasing data since this study began to suggest that acute renal injury may have little impact on long-term outcomes (3). Further study of the treatment of acute heart failure with preserved ejection fraction in multicenter, well-supported trials is clearly needed.
Please note: The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- 2018 American College of Cardiology Foundation
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- Vaishnav J.,
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- for the Osler Medical Housestaff
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