Introduction: Cardiorenal syndrome (CRS) is associated with high morbidity and mortality,recurrent hospitalisations with fluid overload and prolonged length of stays (LOS).
Hypothesis: We assessed the outcome and safety of ambulatory treatment using bolus intravenous (iv) diuretics for fluid overload in chronic CRS patients.
Methods: Our ambulatory heart failure unit (AHFU) is managed by HF specialist nurses with multi-disciplinary approach and regular input from nephrologists and other specialists. The unit also provides bolus IV furosemide (maximum rate 4 mg/kg/minute) in an ambulatory setting. 201 consecutive AHFU patients who received iv diuretics (median follow-up 9 months, range 3-15) were analysed according to CKD stage: I,II (estimated glomerular filteration rate eGFR ≥ 60 ml/min),n=52; III (eGFR 30-59 ml/min), n=118; IV/V(eGFR<30 ml/min), n=31. HF admissions were assessed pre and post AHFU therapy.
Results: Patients with CKD IV/V were older (mean age 76±4.4 years;p=0.03) than CKD III (74±2 years) or CKD I/II patients (69.2±3.8 years). HF with reduced ejection fraction was more prevalent in all groups (I/II 54%, III 61% and IV/V 63%). Serum haemoglobin was lower with worsening CKD: 109 ± 12 g/L in IV/V; 125 ± 6 g/L in III and 129 ± 12 g/L in I/II,p=0.04. Advancing CKD stages were associated with more frequent AHFU visits and higher furosemide doses: CKD IV/V - 4.9 visits, 230±20 mg ;CKD III-3.9 visits, 183 ± 10mg and CKDI/II-3.5 visits, 166 ± 20 mg (p<0.001). Successful fluid off-loading (measured by weight loss) was evident across all groups. However,weight loss diminished with advancing CKD grade: IV/V 3.5%; III 7.7%; I/II 9.3%,(p=0.04). Post-AHFU treatment, HF hospitalisations reduced significantly irrespective of CKD stage and there were no complications due to bolus iv furosemide. Pre-AHFU mean HF admissions in CKD IV/V was 1.01 ± 0.2 with LOS 8.4 days, vs. post 0.1± 0.1; CKD III mean 0.75±0.1 (pre - LOS 4.3 days) vs. 0.07 ± 0.1 (post); CKD I/II mean 0.7 ± 0.2 (pre-LOS 2.6 days) vs. post 0.08 ± 0.01 (p<0.001).
Conclusions: Heart failure patients with chronic cardio-renal syndrome can be safely and efficaciously managed in a specialist nurse-led ambulatory day-case unit. The resultant reductions in HF hospital admissions can also lead to cost-savings.