Acute heart failure is the rapid onset or worsening of symptoms and/or signs of heart failure, which requires urgent evaluation and treatment. It is mostly a clinical diagnosis with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion. In most patients, the major cause for admission is volume overload. Sodium and water retention in the extracellular space is the major mechanism contributing to volume overload and the mainstay of treatment is administration of diuretics, especially loop diuretics, intravenously along with supportive care. Appropriate treatment improves survival and also lowers re-hospitalisation rates.

The appropriate dosing of loop diuretics for patients with acute heart failure is a dynamic process which needs clinical and hemodynamic assessment along with biochemical and echocardiographic analysis. Commonly, peripheral edema, weight changes, urine output and levels of BNP are used as parameters to guide the diuretic dosing.

Natriuresis assessed by urinary spot sodium and spot chloride levels, which is an economical as well as easy to access tool, which if assessed at appropriate intervals will help in guiding diuretic therapy as well as in deciding on ultrafiltration in case of diuretic resistance. This will help in faster decongestion, hence reducing hospital stay as well as improving patient outcomes.

In this study, all patients admitted to our hospital with acute heart failure and over 18years of age will be included. Patients with eGFR<15ml/min, severe hepatic dysfunction or with overt sepsis will be excluded. After collecting the baseline demographics and clinical assessment,  the urine spot sodium and chloride levels in acute heart failure patients at baseline (time of admission), 2hrs, 24hrs and 48hrs post diuretic use, will be obtained and studied for serial increase, noted as response to diuretics. The improvement in the clinical condition with respect to the hospital stay, ICU stay, ventilator requirement and improvement in symptoms will be assessed.

The long term outcomes of re-hospitalisation rates and all cause mortality will be studied for a period of 6 months, following discharge of the patient.

This study will be followed up with the objective of improving the patients’ in hospital outcomes by suggesting ultrafiltration earlier in the hospital stay depending on the diuretic response assessed by urine spot sodium and chloride levels.

Dr. Rashmi Shivram
Resident – Nephrology
Kauvery Hospital, Chennai

Dr B Balaji Kirushnan
Nephrologist
Kauvery Hospital, Chennai