Natriuresis-guided diuretic therapy improves diuresis and natriuresis in patients with heart failure

For this purpose, they conducted the open-label, pragmatic Urinary Sodium-based algoritHm in Acute Heart Failure trial, which included 310 patients with AHF requiring treatment of IV loop diuretics. They were randomly assigned to natriuresis-guided therapy or standard of care (SOC).

In the natriuresis-guided arm, natriuresis was determined at set time points, prompting treatment intensification if spot urinary sodium levels were <70 mmol l−1. The dual primary endpoints included 24-hour urinary sodium excretion and a combined endpoint of time to all-cause mortality or adjudicated heart failure rehospitalization at 180 days.

Key findings include:

• The first primary endpoint was met, as natriuresis in the natriuresis-guided and SOC arms was 409 ± 178 mmol arm versus 345 ± 202 mmol, respectively.
• There were no significant differences between the two arms for the combined endpoint of time to all-cause mortality or first heart failure rehospitalization, which occurred in 31% and 31% of patients in the natriuresis-guided and SOC arms, respectively (hazard ratio 0.92).

An important observation from the PUSH-AHF trial is that natriuresis-guided diuretic therapy was safe and did not lead to more (serious) adverse events or prespecified renal events.

"The PUSH-AHF study provides a first step towards a personalized natriuresis-guided approach in patients with AHF," the investigators concluded.

Reference:

Ter Maaten, J. M., Beldhuis, I. E., Krikken, J. A., Postmus, D., Coster, J. E., Nieuwland, W., Van Veldhuisen, D. J., Voors, A. A., & Damman, K. (2023). Natriuresis-guided diuretic therapy in acute heart failure: A pragmatic randomized trial. Nature Medicine, 1-8. https://doi.org/10.1038/s41591-023-02532-z