Kidney Week

Abstract: TH-OR102

Predictors to Identify Diuretic Resistance Early in Acute Decompensated Heart Failure (ADHF)

Session Information

• Hypertension and CVD: Therapies and Predictors
  November 07, 2019 | Location: 206, Walter E. Washington Convention Center
  Abstract Time: 05:18 PM - 05:30 PM

Category: Hypertension and CVD

• 1402 Hypertension and CVD: Clinical, Outcomes, and Trials

Authors

• Bansal, Shweta, University of Texas Health at San Antonio, San Antonio, Texas, United States

Shweta Bansal, MBBS, MD, FASN



After obtaining medical degree from SMS Medical College, Jaipur and Residency in Internal Medicine from New Delhi, India, Dr. Bansal moved to the Unites States in 2001, where she went on to complete Internal Medicine Residency and Nephrology Fellowship from the University of Colorado, Denver. There she also obtained the certificate in Public Health Sciences. Dr. Bansal joined the Division of Nephrology at UT Health San Antonio in 2010 and currently is an Associate Professor of Medicine. Dr. Bansal adores the pathophysiological role kidneys play in health and diseases, particularly the heart failure, and she is passionate about teaching this role to the medical students, residents, fellows and colleagues. She has been highly recognized for her outstanding teaching abilities and won several teaching awards. In 2018, she was appointed the Program Director of Nephrology Fellowship Program at UT Health San Antonio. Dr. Bansal’s research interest focuses on the volume/sodium control in the management of hypertension, kidney and cardiorenal diseases. Dr. Bansal’s involvement in understanding the interaction of kidneys with other organ systems, particularly the heart, has resulted in Cardiorenal Connections Annual CME meeting in San Antonio, which she has been co-directing with her cardiology colleague Dr. Prasad for last three years with up to 300 attendees. She has also worked on the role of inflammatory pathways in chronic kidney disease. She has received extra-mural and institutional grants to support her translational and clinical research projects. She is also site-PI for important Precision Medicine initiatives with NIH and TRIDENT consortium, NHLBI sponsored SPIRRIT-HF and several clinical industry grants. She has over 40 peer reviewed publications and chapters. Dr. Bansal is an active supporter of the Institutional research endeavors and has been chairing Institutional Review Board since 2015. She is section editor for Journal Clinical Nephrology. Dr. Bansal clinical interests align with her research interests and involve management of resistant hypertension, cardiorenal syndromes, diabetic nephropathy etc. Main goal of her clinical practice and teaching to the fellows is not to dialyze but prevent patients going on dialysis. Dr. Bansal strongly believes that empowerment of patients by health education is the most important step to achieve the best outcomes. Dr. Bansal established the peritoneal/home dialysis program at the partnered University Hospital System and fervently promotes this less-utilized modality to the patients and fellows.

• Munoz, Kristina Marie, Central Michigan University College of Medicine, Mount Pleasant, Michigan, United States

Kristina Marie Munoz,

• Brune, Sonja D., UT Health San Antonio, San Antonio, Texas, United States

Sonja D. Brune,

• Prasad, Anand, UT Health San Antonio, San Antonio, Texas, United States

Anand Prasad,

• Velagapudi, Chakradhar, University of Texas Health at San Antonio, San Antonio, Texas, United States

Chakradhar Velagapudi,

Background

Resistance to loop-diuretics occurs frequently in patients hospitalized for ADHF, resulting in inadequate decongestion, readmission and poor outcomes. Early identification of diuretic resistance during the hospital course may avoid delay in institution of appropriate therapies. We aimed to identify clinical biomarkers that predicted diuretic resistance in a study conducted to evaluate usefulness of high-dose spironolactone in loop-diuretic resistant ADHF patients.

Methods

The parent trial was a prospective, non-randomized trial in ADHF patients. Diuretic resistance was identified if subjects had weight loss<1lb/day despite intravenous furosemide>160mg/day (at least one dose of 80mg/day) or no change in dyspnea 48H after admission with usual care. Baseline clinical characteristics, blood chemistry including neurohormones and urine electrolytes were compared between diuretic-responsive and resistant subjects.

Results

Twenty of 47 enrolled subjects met loop-diuretic resistance criteria. The mean age was 61±15 yrs, 60% were male, and 50% were Hispanic. There was no difference in age, gender and race, co-morbidities, sign and symptoms of hypervolemia, renal function, EF%, presence of pulmonary HTN between diuretic-responsive and resistant subjects. However, serum sodium was lower (137[134,139] vs. 139[137,141]meq/L, p<0.03) and blood urea nitrogen was higher (11.42[7.60,3.18] vs. 7.68[5.71,8.92]mmol/l, p=0.009) in diuretic resistant compared to responsive subjects. Diuretic-resistant subjects had higher plasma renin activity (7.2[1.5,29.5] vs. 2[0.2,10.9]ng/ml/hr, p=0.03) and aldosterone (26.5[9.9, 56] vs. 5.2[3.7, 8.2] ng/dL, p<0.001), and lower urine sodium-potassium ratio (2.63±1.2 vs. 8.2±4.8, p<0.001). Plasma aldosterone had an inverse relationship with urine sodium-potassium ratio and (r=-0.46, p=0.003), but not with serum sodium or urea nitrogen. Urine sodium-potassium ratio at admission predicted loop-diuretic resistance with an AUC (95%CI) 0.69 (0.68, 0.71). A cutoff value of 2.96 had a sensitivity of 76% and specificity of 65% to identify loop-diuretic resistance (lower the value, more the resistance).

Conclusion

The admission urine sodium-potassium ratio may serve as a surrogate for high aldosterone activity, and is an inexpensive and rapidly available biomarker to recognize diuretic resistance in ADHF patients.

Funding

• Commercial Support –