Effects of tolvaptan on urine output in hospitalized heart failure patients with hypoalbuminemia or proteinuria

Impact of urine cyclic AMP relative to plasma arginine vasopressin on response to tolvaptan in patients with chronic kidney disease and heart failure

BACKGROUND

The clinical utility of tolvaptan in chronic kidney disease (CKD) patients with heart failure remains uncertain. The level of urine cyclic adenosine monophosphate (AMP) relative to plasma arginine vasopressin (AVP) indicates the residual function of the collecting ducts in response to AVP stimulation and might be a key to predicting response of tolvaptan.

METHODS

CKD patients who were hospitalized to treat their congestive heart failure refractory to conventional loop diuretics were considered to receive tolvaptan and included in this prospective study. The impact of urine cyclic AMP/plasma AVP ratio for prediction of response to tolvaptan, which was defined as any increase in urine volume at day 7 from day 0, was investigated.

RESULTS

A total of 30 patients (median 75 years old, 24 men, and median estimated glomerular filtration rate 14.4 mL/min/1.73 m²) were included. As compared to baseline, urine volume increased at day 7 in 17 responders, whereas urine volume decreased at day 7 in 13 non-responders. Baseline urine cyclic AMP/plasma AVP ratio distributed between 0.25 and 4.01 with median 1.90. The urine cyclic AMP/plasma AVP ratio was a significant predictor of response to tolvaptan, which was adjusted for 6 potential confounders with a cutoff of 1.24.

CONCLUSIONS

Baseline urine cyclic AMP/plasma AVP ratio is an independent predictor of response to tolvaptan in advanced CKD patients with heart failure.

CLINICAL TRIAL REGISTRATION

UMIN000022422.

Tolvaptan treatment in an adult Fontan patient with protein-losing enteropathy: a serial 23Na-MRI investigation

Background:

Protein-losing enteropathy (PLE) is a severe complication of the univentricular Fontan circulation and associated with disturbances in salt and water homeostasis. Fontan patients with PLE have a poor prognosis, with increased morbidity and mortality. Due to limited therapeutic strategies, patients are often treated only symptomatically.

Methods:

We report our first experience of Tolvaptan (TLV) treatment in a Fontan patient with PLE, severe volume retention and hyponatraemia, refractory to conventional diuretic therapy. In addition to clinical parameters, we monitored drug effects including tissue sodium and volume status via serial ²³Na-magnetic resonance imaging (²³Na-MRI) and bioimpedance spectroscopy compared with age-matched controls.

Results:

²³Na-MRI identified elevated tissue sodium, which decreased under TLV treatment, as well as volume status, while serum sodium increased and the patient’s symptoms improved. During long-term treatment, we were able to differentiate between sodium and volume status in our patient, suggesting that TLV uncoupled body sodium from water.

Conclusion:

TLV in addition to loop diuretics improved clinical symptoms of PLE and lowered tissue sodium overload. Long-term effects should be further evaluated in Fontan patients.

Different Effects on Fluid Distribution between Tolvaptan and Furosemide in a Liver Cirrhosis Patient with Chronic Kidney Disease

A 73-year-old man with liver cirrhosis and advanced chronic kidney disease was admitted to our hospital due to bilateral lower leg edema and appetite loss. Furosemide to treat fluid retention markedly decreased extracellular water compared with intracellular water, but the addition of tolvaptan equally decreased both with a greater diuretic response than furosemide alone. Furthermore, tolvaptan administration increased the plasma colloid osmotic pressure, which might facilitate the shift of fluid from the extravascular space to the intravascular space. This is the first case showing different effects on the fluid distribution between furosemide and additional tolvaptan in the same patient.

Prognostic factors for long-term outcomes in acute decompensated heart failure patients under tolvaptan treatment

Inconsistent results have been reported concerning the effect of tolvaptan treatment on long-term prognostic outcomes in patients with acute decompensated heart failure (ADHF) and data are limited on prognostic factors affecting this patient population. We investigated prognostic factors influencing long-term clinical outcomes in patients with ADHF treated with tolvaptan in a real-world setting. A total of 263 consecutive patients hospitalized for ADHF and treated with tolvaptan were retrospectively enrolled. The patients were stratified into those who developed the combined event of cardiac death or rehospitalization for worsening heart failure within 1 year (n = 108) and those who were free of this combined event within 1 year (n = 155). Adjusted multivariate Cox proportional hazards model revealed that change in serum sodium level between pre-treatment and 24 h after tolvaptan administration [hazard ratio (HR) 0.913, 95% confidence interval (CI) 0.841-0.989, p = 0.025] and the time taken for tolvaptan initiation from admission (HR 1.043, 95% CI 1.009-1.074, p = 0.015) were independent predictors of combined event occurrence within 1 year. Moreover, change in serum sodium level > 1 mEq/L between pre-treatment and 24 h after administration and initiation of tolvaptan < 5 days after admission correlated significantly with the incidence of the combined event (log-rank test p = 0.003 and p = 0.002, respectively). In conclusion, increased serum sodium level early after administration and early initiation of tolvaptan are possibly useful for assessing the long-term prognosis after tolvaptan treatment in patients with ADHF.