Author + information
- Received October 24, 2018
- Revision received January 11, 2019
- Accepted January 14, 2019
- Published online April 29, 2019.
- Daniel Z. Hodson, BAa,∗,
- Matthew Griffin, MDa,∗,
- Devin Mahoney, BSa,
- Parinita Raghavendra, MSa,
- Tariq Ahmad, MD, MPHa,
- Jeffrey Turner, MDb,
- F. Perry Wilson, MD, MSb,
- W.H. Wilson Tang, MDc,
- Veena S. Rao, PhDa,
- Sean P. Collins, MDd,
- Wilfried Mullens, MD, PhDe and
- Jeffrey M. Testani, MD, MTRa,∗ ()
- aSection of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
- bSection of Nephrology, Yale University School of Medicine, New Haven, Connecticut
- cDepartment of Cardiovascular Medicine, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
- dDepartment of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- eDepartment of Cardiology, Ziekenhuis Oost Limburg, Genk–Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University Diepenbeek, Belgium
- ↵∗Address for correspondence:
Dr. Jeffrey M. Testani, Section of Cardiovascular Medicine, Yale School of Medicine, 135 College Street, Suite 230, New Haven, Connecticut 06510.
Objectives This study sought to describe sodium excretion in acute decompensated heart failure (ADHF) clearly and to evaluate the prognostic ability of urinary sodium and fluid-based metrics.
Background Sodium retention drives volume overload, with fluid retention largely a passive, secondary phenomenon. However, parameters (urine output, body weight) used to monitor therapy in ADHF measure fluid rather than sodium balance. Thus, the accuracy of fluid-based metrics hinges on the contested assumption that urinary sodium content is consistent.
Methods Patients enrolled in the ROSE-AHF (Renal Optimization Strategies Evaluation-Acute Heart Failure) trial with 24-h sodium excretion available were studied (n = 316). Patients received protocol-driven high-dose loop diuretic therapy.
Results Sodium excretion through the first 24 h was highly variable (range 0.12 to 19.8 g; median 3.63 g, interquartile range: 1.85 to 6.02 g) and was not correlated with diuretic agent dose (r = 0.06; p = 0.27). Greater sodium excretion was associated with reduced mortality in a univariate model (hazard ratio: 0.80 per doubling of sodium excretion; 95% confidence interval: 0.66 to 0.95; p = 0.01), whereas gross urine output (p = 0.43), net fluid balance (p = 0.87), and weight change (p = 0.11) were not. Sodium excretion of less than the prescribed dietary sodium intake (2 g), even in the setting of a negative net fluid balance, portended a worse prognosis (hazard ratio: 2.02; 95% confidence interval: 1.17 to 3.46; p = 0.01).
Conclusions In patients hospitalized with ADHF who were receiving high-dose loop diuretic agents, sodium concentration and excretion were highly variable. Sodium excretion was strongly associated with 6-month mortality, whereas traditional fluid-based metrics were not. Poor sodium excretion, even in the context of fluid loss, portends a worse prognosis.
↵∗ Mr. Hodson and Dr. Griffin contributed equally to this work.
This work was supported by National Institutes of Health (NIH) grants K23HL114868, L30HL115790, R01HL139629, R21HL143092, R01HL128973 (Dr. Testani), K23DK097201 (Dr. Wilson), and T32 training grant 5T32HL007950 (Dr. Griffin). Dr. Tang has received consultant fees from Sequana Medical and MyoKardia. Dr. Collins has been a consultant for Novartis, Vixiar, Ortho Clinical, and Medtronic; and has received research support from Ortho Clinical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received October 24, 2018.
- Revision received January 11, 2019.
- Accepted January 14, 2019.
- 2019 American College of Cardiology Foundation
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