Impact of chronic kidney disease on the diuretic response of tolvaptan in acute decompensated heart failure

Abstract

Aim: This study investigated the relationship between the initial diuretic response to tolvaptan and clinical predictors for tolvaptan responders in patients with acute decompensated heart failure (ADHF).

Methods and results: Patients (153) with ADHF (clinical scenario 2 or 3 with signs of fluid retention) who were administered tolvaptan were enrolled. Tolvaptan (15 or 7.5 mg) was administered for at least 7 days to those patients in whom fluid retention was observed even after standard treatment. The maximum urine volume immediately after tolvaptan administration showed good correlations with the ejection fraction and estimated glomerular filtration rate that were independent predictors of the urine volume (UV) responders (≥1500 mL increase in urine volume). The diuretic response (in terms of maximum diuresis) diminished with advancing chronic kidney disease (CKD) stage and concomitant deterioration of the renal function. Furthermore, advanced CKD was a significant negative predictor for the body weight (BW) responders (2.0% decrease in the body weight within 1 week after starting tolvaptan). As compared with non-CKD, the presence of advanced CKD predicts poor diuretic response for both UV and BW responders.

Conclusions: The diuretic response following tolvaptan administration gradually diminished with progressive deterioration of the CKD stage. Worsening renal function was not observed. Tolvaptan is effective in treating CS2 or CS3 ADHF patients who present fluid retention and congestion, suggesting its potential efficacy for fluid management in the ADHF patients with CKD without worsening the renal function.

Keywords: Acute decompensated heart failure; Chronic kidney disease; Diuretic response; Tolvaptan.

Figure 1

Correlation between the estimated glomerular filtration rate (GFR) and maximum urine volume following administration of tolvaptan.

Figure 2

Distribution of maximum urine volume in each chronic kidney disease stage.

Figure 3

Urine volume responder rate categorized by the combination of chronic kidney disease and ejection fraction. HFrEF, EF > 50%; HFpEF, EF < 50%; non‐CKD, stages 1–2; CKD, stages 3–5. CKD, non‐chronic kidney disease; HFpEF, heart failure with preserved ejection fraction; HFrEF, heart failure in settings of reduced ejection fraction.

Figure 4

Body weight responder rate of non‐CKD and CKD group. CKD, chronic kidney disease. Non‐CKD, stages 1–2; CKD, stages 3–5.