For those who can't get enough from #ADVOR, below the promised Tweetorial!
Acetazolamide in acute #HeartFailure w volume overload on background high-dose loop diuretics:
👍Increases diuresis & natriuresis
👍More euvolemia after 3 days & discharge
👍⬇️LOS #ESCCongress#Cardiology
First, the unsung hero's of this trial, done with a little bit over 2 million €, bargain for largest diuretic #RCT ever! @KatrienTartagl2 & her team, with only 3FTE, they ran the most successful trial in #AHF @PieterMartensMD & @JeroenDauw who did most fieldwork
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How did we come up with the idea? Actually, cause we all love #physiology. Credits go to Prof. Em. Paul Steels who teached us all how kidneys work. @GLW_UHasselt
65% of sodium is reabsorbed in the proximal tubules, can be up to 85% in #HeartFailure
Proximal diuretics ➡️more distal flow➡️give kidneys back control on homeostasis (they are far better than cardiologists)
Also, more chloride from proximal to the macula densa sensor acts like a break on the neurohumoral system.
Read everything about it in our review @ESC_Journals@JACCJournals:
Challenge in #ADVOR: which endpoint in acute #HeartFailure trial?
- Impossible to power for mortality/heart failure readmissions (probably influenced a lot more by chronic treatment & disease severity)
- First idea was natriuresis with secondary endpoint of clinical decongestion
Funder @KCEfgov made us promote the secondary endpoint to the primary and gave us the leverage to include more patients.
Diuretics treat volume overload🚫pressure, that's why we ended up with these 3 pivotal signs (flash lung edema occur even with normal volume)
Pay attention on background infusion of 500 mL Dextrose 5% with 3 g MgSO4, You will lose more magnesium (and potassium) with acetazolamide. Because it increases free water excretion, the dextrose is not a problem. It's the salt You are after!
Everybody knows the result by now: nearly 12% more patients dry after 3 days!
Importantly, can't make up for a missed opportunity! AFTER randomised treatment period, decongestion curves keep separating. Remember that #acetazolamide is a break on the neurohumoral system. You don't break when Your already over the cliff!
We could decrease length of stay with 1 day, imagine the impact if this strategy would be employed on a more systematic base worldwide?
My only concern: very cheap drug produced by one generic company, please don't let this become an expensive medicine
Do You keep slamming Your face because You missed the 1st #HFA@escardio Clinical Practice Update Course on #HeartFailure, orchestrated masterfully by MC Mullens?
I'll release just a teaser under the form of a clinical case below. You might call on my partners in crime @Ph_Bertrand & @petranijst to do the same...
How is diuretic efficiency changing with severity of #CKD? What is its prognostic relevance?
Read our new paper in CardioRenal Medicine!
@WilsonTangMD@BammensBert
Also thanks to Jeff Testani, Pieter Martens & Dirk Kuypers for their help with the paper...
We used 3 metrics of diuretic efficiency, based on urine output, natriuresis & chloruresis.
Irrespectively of metric, loop diuretic efficiency decreased significantly from KDIGO class IV, while remaining relatively preserved in less advanced CKD.
Patterns were similar for furosemide versus bumetanide (very little patients were on torsemide, which is hardly used in Belgium). Yet, baseline characteristics were strikingly different with bumetanide users older with higher cardiovascular risk.
Key points: 1. Spironolactone = most cost-effective drug in #HFrEF 2. Considering modest diuretic effects with 25-50mg, likely due to pleiotropic effects (Figure) 3. Natriuretic effects increase with dosing up to 600 mg (cirrhosis) 4. Average TOPCAT ~ RALES dose
5. Current study shows marginal (<1%) & short-term (first 8 months) effect on weight loss in TOPCAT Americas.
Spiro patients gradually had lower diuretic need and RAS blockers more frequently withdrawn. 6. Beneficial effects of spironolactone independent of these trends
Why #kidney function does not equal #GFR (and certainly not Cr), making it an elusive target in clinical practice & the latter a poor surrogate outcome, despite its robust correlation with prognosis. Caring for kidneys versus improving Cr/GFR. A thread below:
The kidneys in essence have 3 functions: 1. Glomerular function = Clearance 2. Tubular function = Homeostasis 3. Neurohumoral function
GFR mainly reflects 1. So why do we take GFR (or its estimate Cr) as a surrogate for renal function?
Look at GFR determinants (=N x snGFR).
In stable circumstances, GFR mainly reflects the number of functional nephrons.
Starting from 1 million per kidney at birth, one loses 5,000-10,000 per year with aging: age-related GFR decline <1 mL/min/1.73m²/y
Ever since I read this great paper, tend to consider volume status and cardiac filling pressures as 2 separate and equally important concepts that both deserve optimisation in #ICU and #HeartFailure.
Basically, V-p correlation is all over the place! (1/6) journal.chestnet.org/article/S0012-…
What I learned from you all is that #VExUS & especially portal vein flow is a great tool to assess the impact of ⬆️(right-sided) pressure on organ function. This gives you more confidence to diurese patients, even when hypotensive or still hemodynamic unstable. (2/6)