Real World Use of Hypertonic Saline in Refractory Acute Decompensated Heart Failure: A U.S. Center's Experience

Abstract

Objectives: The purpose of this study was to investigate real world safety and efficacy of hypertonic saline therapy in cases of refractory acute decompensated heart failure (ADHF) at a large U.S. academic medical center.

Background: Hypertonic saline therapy has been described as a potential management strategy for refractory ADHF, but experience in the United States is limited.

Methods: A retrospective analysis was performed in all patients receiving hypertonic saline for diuretic therapy-resistant ADHF at the authors' institution since March 2013. The primary analytic approach was a comparison of the trajectory of clinical variables prior to and after administration of hypertonic saline, with secondary focus on predictors of treatment response.

Results: A total of 58 hypertonic saline administration episodes were identified across 40 patients with diuretic-therapy refractory ADHF. Prior to hypertonic saline administration, serum sodium, chloride, and creatinine concentrations were worsening but improved after hypertonic saline administration (p < 0.001, all). Both total urine output and weight loss significantly improved with hypertonic saline (p = 0.01 and <0.001, respectively). Diuretic efficiency, defined as change in urine output per doubling of diuretic dose, also improved over this period (p < 0.01). There were no significant changes in respiratory status or overcorrection of serum sodium with the intervention.

Conclusions: In a cohort of patients who were refractory to ADHF, hypertonic saline administration was associated with increased diuretic efficiency, fluid and weight loss, and improvement of metabolic derangements, and no adverse respiratory or neurological signals were identified. Additional study of hypertonic saline as a diuretic adjuvant is warranted.

Keywords: cardiorenal; diuretic resistance; sodium regulation.

FIGURE 1. Safety Profile of Hypertonic Saline

(A, B) Trends in respiratory measurements before and after initiation of treatment with HS. There were no changes in the percentage of patients who required supplemental oxygen (p = 0.19). The mean FiO₂ (p = 0.50) in the 48 h before HS administration, compared with the 48 h after administration. Histograms of changes in serum sodium at (C) 6 h and (D) 24 h after initiation of treatment with HS. FiO₂ = fraction of inspired oxygen; HS = hypertonic saline.

FIGURE 2. Trends of Diuretic Efficiency Before and After Initiation of Treatment With Hypertonic Saline

There was a significant improvement in diuretic efficiency in the 72 h prior to hypertonic saline (HS) administration compared that in the 72 h after administration (p = 0.01). Diuretic efficiency is defined as the increase in urine output per doubling of loop diuretic dose.

FIGURE 3. Trends of Blood Chemistries Before and After Initiation of Treatment With HS

Improvements were seen in the trends of serum sodium (A, p < 0.01), serum chloride (B, p < 0.001), blood urea nitrogen [BUN] (C, p = 0.15), and serum creatinine (D, p < 0.001) after hypertonic saline (HS) administration, whereas there was no statistically significant change in the trend of BUN before and after administration (p = 0.15).

CENTRAL ILLUSTRATION. Patients Receiving HS Had Improved Urine Output and Weight Loss

Patients receiving hypertonic saline (HS) had improved urine output and weight loss, without dangerous fluctuations in serum sodium or respiratory decompensation. There were no changes in the percentage of patients requiring supplemental oxygen, and fluctuations in serum sodium were within the acceptable range following administration of hypersonic saline. Both total urine output and weight loss improved.