Urine sodium-guided diuresis in acute heart failure: a systematic review and meta-analysis of efficacy and safety.

INTRODUCTION

Acute heart failure (AHF) is a leading cause of hospitalization among older adults and is associated with high rates of rehospitalization and mortality. Intravenous diuretics are the cornerstone of treatment, but diuretic response is highly variable. Spot urine sodium measurement has emerged as a novel tool to guide diuretic titration. We aim to evaluate the efficacy and safety of urine sodium-guided diuresis (USGD) compared to standard of care (SOC) in AHF.

METHODS

Online databases were searched. Outcomes included 48-hour natriuresis, 48-hour diuresis, 48-hour weight loss, length of stay (LOS), all-cause mortality, heart failure (HF) rehospitalization, acute kidney injury (AKI), hypotension and hypokalemia. These were reported as risk ratio (RR) for categorical outcomes and mean difference (MD) for continuous outcomes with a random effects model using 95% confidence intervals (CI).

RESULTS

Five studies with 920 patients were selected. USGD was associated with an increased 48-hour natriuresis (MD = 139.13 mmol [95% CI: 4.84, 273.43], p = 0.047) and diuresis (MD = 1.12 L [95% CI: 0.09, 2.15], p = 0.043) and a lower risk of AKI (RR = 0.51 [95% CI: 0.27, 0.97], p = 0.039). There were no significant differences in 48-hour weight loss (MD = 0.45 kg), LOS (MD=-0.38 days), all-cause mortality (RR = 0.93), HF rehospitalization (RR = 0.91), hypotension (RR = 1.06), or hypokalemia (RR = 0.97).

CONCLUSION

USGD was associated with an increased 48-hour natriuresis and diuresis and a lower risk of AKI compared to SOC in AHF. However, there was no difference in 48-hour weight loss, LOS, all-cause mortality, HF rehospitalization, hypotension, or hypokalemia. While USGD improved short-term natriuresis and renal safety endpoints, further randomized trials are needed to determine optimal urine sodium thresholds and long-term outcomes.