Introduction
The majority of acute decompensated heart failure (ADHF) admissions are driven by
congestion. Sodium is the primary pathophysiologic driver of volume retention, with
water passively following. However, monitoring sodium output in routine clinical practice
is challenging. We previously created a model, the natriuretic response prediction
equation (NRPE), to predict total sodium excretion following an IV dose of loop diuretic.
The NRPE requires only a spot urine sodium and creatinine obtained 2 hours following
diuretic administration (Figure 1). The objective of this study was to externally
validate the NRPE.
Hypothesis
NRPE will accurately predict 6 hour post loop diuretic sodium output.
Methods
A total of 638 urine collections from 409 patients hospitalized with ADHF undergoing
intravenous loop diuretic therapy were included. Intensively supervised urine collections
were performed, and urine spot samples were taken at 2 hours after loop diuretic administration.
A poor natriuretic response was defined as a sodium output of <50 mmol, suboptimal
<100 mmol, and excellent >150 mmol within this 6-hour period.
Results
The median IV furosemide equivalent dose was 80 mg (40-160), resulting in a cumulative
6-hour sodium output of 85 mmol (50-143) and urine output of 960 mL (640-1410). Poor
natriuretic response was observed in 25% of the urine collections, averaging a cumulative
sodium output of 29±13 mmol. Suboptimal and excellent responses were seen in 57% and
21% of the visits. The NRPE accurately predicted poor, suboptimal, and excellent natriuretic
response, with an AUC of 0.92, 0.90, and 0.90, respectively (p<.001 for all). Conversely,
clinically obtained net fluid output and spot-sample sodium concentration showed lower
ability to predict poor (AUC 0.82, 0.89), suboptimal (AUC 0.80, 0.84), and excellent
natriuretic responses (AUC 0.85, 0.81), respectively.
Conclusions
The NRPE, using only a 2 hour post diuretic spot urine sample, is a rapid and highly
accurate method to monitor natriuretic response in ADHF patients.
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Copyright
© 2020 Published by Elsevier Inc.
