Small, single-center study challenges salt restriction during IV diuresis for acute HF
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NATIONAL HARBOR, Md. — Oral sodium chloride supplementation during IV diuresis resulted in similar changes in serum creatinine and body weight at 96 hours vs. placebo in patients hospitalized for acute HF, a speaker reported.
The results of the Oral Sodium to Preserve Renal Efficiency in Acute HF (OSPREY-AHF) trial were presented at the Heart Failure Society of America Annual Scientific Meeting.
“In favor of choosing a low-sodium diet would be simple logic, that acute heart failure is manifested by salt and water retention, and thus, a low-salt diet may prevent congestion and aid decongestion,” Robert A. Montgomery, MD, cardiologist at Cleveland Clinic Lerner College of Medicine of Case Western Reserve University as opposed to Case Western Reserve University School of Medicine, said during a presentation. “Observational data suggests that a low-salt diet also decreases heart failure admissions. But a low-sodium diet is not without concerns. That low-salt diets can be associated with decreased nutritional quality and caloric intake. Additionally, low-sodium diets can be associated with increased neurohormonal activation with renin-angiotensin symptom activation, increasing renal sodium avidity and decreasing a diuretic response.
“Some data support giving sodium chloride in acute heart failure in the form of hypertonic saline to mitigate the neurohormonal activation with the hope to decrease real sodium avidity and increase a diuretic response,” Montgomery said. “Society guidelines give no recommendations in acute heart failure for sodium restriction and list this as an evidence gap in future research.”
OSPREY-AHF was a single-center, double-blind, randomized controlled trial that enrolled 65 patients hospitalized at Cleveland Clinic with acute HF (mean age, 70 years; 37% women; 14% Black) designed to compare the short-term efficacy and safety of thrice daily oral sodium chloride 2 g with placebo during IV diuresis for up to 96 hours.
The primary endpoint was change in creatinine and weight at 96 hours.
The average patient had hypertension, CAD, obesity and HF with moderately reduced ejection fraction with two prior hospitalizations in the past year and was being treated with an average furosemide infusion of 15 mg per hour, Montgomery said during the presentation.
The mean load of sodium chloride administered to each patient was 13 g.
Montgomery stated that the daily dose of oral sodium chloride administered in OSPREY-AHF was approximately equivalent to the sodium content of six large servings of fast-food french fries.
At baseline, serum creatinine was lower in the sodium chloride group compared with placebo (2 vs. 1.6 mEq/L; P = .04); however, estimated glomerular filtration rate did not differ between the two groups (37 vs. 42 mL/min/1.73 m2; P = .18), respectively.
At 96 hours, there was no significant difference among patients treated with sodium chloride and those who received placebo for the primary endpoint of change in creatinine (0.04 vs. 0.15 mg/dL; P = .3) and weight (–4 vs. –4.6 kg; P = .57), respectively.
The researchers noted a smaller mean decrease in serum sodium (–0.03 vs. –2.6; P < .001) and a smaller mean increase blood urea nitrogen (3.1 vs. 11 mEq/L; P = .02) in patients who received oral sodium chloride compared with placebo.
Although the trial was not powered to detect a difference in serious adverse events, the researchers reported that they observed none.
“We believe that the null result of this study does challenge the routine practice of sodium chloride restriction in acute heart failure, something done thousands of times a day, millions of times a year,” Montgomery said. “While underpowered, the absence of demonstrable harm of sodium chloride during IV diuretic therapy suggests larger clinical trials are possible and necessary.”
Perspective
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Certainly, our classical approach is to restrict sodium intake and the data seemed, at least in this relatively small study, to raise the hypothesis that you don’t need to do that. We need much more data. It’s a small study, but certainly it does lay the groundwork for a larger randomized trial. But it at least points that it would probably be safe to do that trial. I think OSPREY was an important study.
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Montgomery RA, et al. Late Breaking Clinical Trials Session I. Presented at: The Heart Failure Society of America Annual Scientific Meeting; Sept. 30-Oct. 3, 2022; National Harbor, Maryland (hybrid meeting).
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