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Dauw J, Meekers E, Martens P, Deferm S, Dhont S, Marchal W, Mesotten L, Dupont M, Nijst P, Tang WHW, Janssens SP, Mullens W. Sodium loading in ambulatory patients with heart failure with reduced ejection fraction: Mechanistic insights into sodium handling. Eur J Heart Fail 2024. [PMID: 38247136 DOI: 10.1002/ejhf.3131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Revised: 11/17/2023] [Accepted: 12/25/2023] [Indexed: 01/23/2024] Open
Abstract
AIMS Sodium restriction was not associated with improved outcomes in heart failure patients in recent trials. The skin might act as a sodium buffer, potentially explaining tolerance to fluctuations in sodium intake without volume overload, but this is insufficiently understood. Therefore, we studied the handling of an increased sodium load in patients with heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS Twenty-one ambulatory, stable HFrEF patients and 10 healthy controls underwent a 2-week run-in phase, followed by a 4-week period of daily 1.2 g (51 mmol) sodium intake increment. Clinical, echocardiographic, 24-h urine collection, and bioelectrical impedance data were collected every 2 weeks. Blood volume, skin sodium content, and skin glycosaminoglycan content were assessed before and after sodium loading. Sodium loading did not significantly affect weight, blood pressure, congestion score, N-terminal pro-brain natriuretic peptide, echocardiographic indices of congestion, or total body water in HFrEF (all p > 0.09). There was no change in total blood volume (4748 ml vs. 4885 ml; p = 0.327). Natriuresis increased from 150 mmol/24 h to 173 mmol/24 h (p = 0.024), while plasma renin decreased from 286 to 88 μU/L (p = 0.002). There were no significant changes in skin sodium content, total glycosaminoglycan content, or sulfated glycosaminoglycan content (all p > 0.265). Healthy controls had no change in volume status, but a higher increase in natriuresis without any change in renin. CONCLUSIONS Selected HFrEF patients can tolerate sodium loading, with increased renal sodium excretion and decreased neurohormonal activation.
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Affiliation(s)
- Jeroen Dauw
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
- UHasselt - Hasselt University, Doctoral School for Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Evelyne Meekers
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
- UHasselt - Hasselt University, Doctoral School for Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Pieter Martens
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
| | - Sébastien Deferm
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
| | - Sebastiaan Dhont
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
- UHasselt - Hasselt University, Doctoral School for Medicine and Life Sciences, LCRC, Diepenbeek, Belgium
| | - Wouter Marchal
- UHasselt - Hasselt University, Institute for Materials Research (IMO-IMOMEC), Diepenbeek, Belgium
| | - Liesbeth Mesotten
- Ziekenhuis Oost-Limburg, Department of Nuclear Medicine, Genk, Belgium
| | - Matthias Dupont
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
| | - Petra Nijst
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
| | | | - Stefan P Janssens
- Department of Cardiovascular Diseases, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Wilfried Mullens
- Ziekenhuis Oost-Limburg, Department of Cardiology, Genk, Belgium
- Faculty of Medicine and Life Sciences, LCRC, UHasselt - Hasselt University, Biomedical Research Institute, Diepenbeek, Belgium
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Hanberg JS, Rao V, Ter Maaten JM, Laur O, Brisco MA, Perry Wilson F, Grodin JL, Assefa M, Samuel Broughton J, Planavsky NJ, Ahmad T, Bellumkonda L, Tang WHW, Parikh CR, Testani JM. Hypochloremia and Diuretic Resistance in Heart Failure: Mechanistic Insights. Circ Heart Fail 2017; 9:CIRCHEARTFAILURE.116.003180. [PMID: 27507113 DOI: 10.1161/circheartfailure.116.003180] [Citation(s) in RCA: 88] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 07/19/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Recent epidemiological studies have implicated chloride, rather than sodium, as the driver of poor survival previously attributed to hyponatremia in heart failure. Accumulating basic science evidence has identified chloride as a critical factor in renal salt sensing. Our goal was to probe the physiology bridging this basic and epidemiological literature. METHODS AND RESULTS Two heart failure cohorts were included: (1) observational: patients receiving loop diuretics at the Yale Transitional Care Center (N=162) and (2) interventional pilot: stable outpatients receiving ≥80 mg furosemide equivalents were studied before and after 3 days of 115 mmol/d supplemental lysine chloride (N=10). At the Yale Transitional Care Center, 31.5% of patients had hypochloremia (chloride ≤96 mmol/L). Plasma renin concentration correlated with serum chloride (r=-0.46; P<0.001) with no incremental contribution from serum sodium (P=0.49). Hypochloremic versus nonhypochloremic patients exhibited renal wasting of chloride (P=0.04) and of chloride relative to sodium (P=0.01), despite better renal free water excretion (urine osmolality 343±101 mOsm/kg versus 475±136; P<0.001). Hypochloremia was associated with poor diuretic response (odds ratio, 7.3; 95% confidence interval, 3.3-16.1; P<0.001). In the interventional pilot, lysine chloride supplementation was associated with an increase in serum chloride levels of 2.2±2.3 mmol/L, and the majority of participants experienced findings such as hemoconcentration, weight loss, reduction in amino terminal, pro B-type natriuretic peptide, increased plasma renin activity, and increased blood urea nitrogen to creatinine ratio. CONCLUSIONS Hypochloremia is associated with neurohormonal activation and diuretic resistance with chloride depletion as a candidate mechanism. Sodium-free chloride supplementation was associated with increases in serum chloride and changes in several cardiorenal parameters. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02031354.
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Affiliation(s)
- Jennifer S Hanberg
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - Veena Rao
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - Jozine M Ter Maaten
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - Olga Laur
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - Meredith A Brisco
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - F Perry Wilson
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - Justin L Grodin
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - Mahlet Assefa
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - J Samuel Broughton
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - Noah J Planavsky
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - Tariq Ahmad
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - Lavanya Bellumkonda
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - W H Wilson Tang
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - Chirag R Parikh
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.)
| | - Jeffrey M Testani
- From the Program of Applied Translational Research (J.S.H., V.R., J.M.t.M., O.L., F.P.W., M.A., J.S.B., C.R.P., J.M.T.) and Department of Internal Medicine (F.P.W., T.A., L.B., C.R.P., J.M.T.), Yale University School of Medicine, New Haven, CT; Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (J.M.t.M.); Cardiovascular Division, Department of Medicine, Medical University of South Carolina, Charleston (M.A.B.); Clinical Epidemiology Research Center, Veterans Affairs Medical Center, West Haven, CT (F.P.W.); Section of Heart Failure and Cardiac Transplantation, the Cleveland Clinic, OH (J.L.G., W.H.W.T.); and Department of Geology and Geophysics, Yale University, New Haven, CT (N.J.P.).
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