Diagnosing and Targeting Mechanisms of Diuretic Resistance in Heart Failure

Study Overview
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Brief Summary
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Effective diuresis is the primary goal of most acute decompensated heart failure hospitalizations, but diuretic resistance is common and our ability to detect it is limited. Further, there are therapeutically distinct groups of diuretic-resistant patients. These are not easily distinguished using currently available methods, leading to trial-and-error based treatment that promotes lengthy hospitalizations. The aims of this study are: To develop inexpensive and efficient tools to predict diuretic response To understand the prevalence of therapeutically targetable mechanisms of diuretic resistance using endogenous lithium clearance To develop methodology to differentiate diuretic resistance mechanisms using common/inexpensive laboratory tests To provide proof of concept that mechanistically tailored diuretic therapy can improve natriuresis

Detailed Description
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This study is a minimal-risk observational open-label single center study with randomization between two standard of care interventions. Approximately 500 patients admitted to the hospital (Yale New Haven Health System) with a clinical diagnosis of heart failure will be enrolled in the overall study. Patients will undergo sampling of their blood and collection of urine at a minimum of 4 timepoints (called visits), or a minimum of 5 in the interventional arm. Patients with a low urine sodium output (<100 mmol) on Visit 1 will be eligible for 1:1 randomization to either an increased dose of their Visit 1 loop diuretic or addition of IV chlorothiazide to their Visit 1 loop diuretic.

Official Title
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Diagnosing and Targeting Mechanisms of Diuretic Resistance in Heart Failure

Conditions
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Heart Failure

Intervention / Treatment
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* Drug: Increased Intravenous Bolus Loop Diuretic Dose (Bumetanide or Furosemide)
* Drug: IV Chlorothiazide


Participation Criteria
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Eligibility Criteria
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For all patients: Inclusion criteria: Age ≥ 18 years Clinical diagnosis of ADHF with at least one objective sign of volume overload: rales, edema, elevated JVP, preadmission weight gain Current use of bolus IV loop diuretic therapy and projected need by the treating clinician for continued treatment with IV diuretics for at least 3 days with the goal of significant fluid removal (>1L net fluid loss/day) Exclusion criteria: Inability to perform informed consent or comply with the serial urine collection procedures Significant bladder dysfunction or urinary incontinence Hematocrit less than 21% or active bleeding For patients in the interventional arm: Inclusion criteria: Cumulative 6-hour sodium output < 100 mmol following Visit 1 IV loop diuretic dose Visit 1 IV loop diuretic dose ≤ 160 mg of furosemide equivalents Serum sodium > 125 mmol/L At least 6 hours since last dose of diuretic Exclusion criteria: Current use or projected future requirement by the treating physician for thiazide diuretics Use of high dose mineralocorticoid receptor antagonist therapy (>50mg of spironolactone or >100mg of eplerenone) or amiloride

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Diagnostic
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Increased Intravenous Loop Diuretic (Bumetanide or Furosemide)<br>2.5x Visit 1 dose | Drug: Increased Intravenous Bolus Loop Diuretic Dose (Bumetanide or Furosemide)<br>* An increase to 2.5x the Visit 1 dose of loop diuretic (bumetanide or furosemide).<br>|
| Experimental: Loop Diuretic (Bumetanide or Furosemide) + IV Chlorothiazide<br>Loop diuretic (Bumetanide or Furosemide) dose remains the same as visit 1 dose but now with the addition of 500-1000 mg IV chlorothiazide | Drug: IV Chlorothiazide<br> <br> |
| No Intervention: Observational Arm<br>Subjects taking an IV loop diuretic (Bumetanide or Furosemide) that have sodium output greater than 100 mmol. These subjects will continue to be followed and have data collected on them. | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Accuracy of sodium prediction equation in predicting suboptimal natriuretic response to a dose of diuretics | Suboptimal Natriuretic Response is defined as a measured sodium output of <100 mmol in the 6 hours following the dose of diuretic | 6 hours | 
| Prevalence of mechanistic sub types of Diuretic Resistance (DR) as defined by cutoff values of change in fractional excretion of lithium | Descriptions of the prevalence of the DR mechanisms at the different time points in the study will be reported. | 6 hours | 
| Accuracy of prediction of mechanistic sub types of DR using universally available laboratory tests | The relationship between the change in fractional excretion of potassium and sodium and the change in fractional excretion of endogenous lithium will be assessed in order to develop methodology to identify the etiology of DR using universally available laboratory tests. | 6 hours | 
| Change in total 6-hour sodium output between observational and randomized intervention study days | Sodium output in response to a dose of diuretics will be measured via urine collection. | 6 hours | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Prediction of mechanistic sub types of DR | Relationship between the fractional excretion of magnesium or calcium with the fractional excretion of endogenous lithium will also be assessed | 6 hours |