الفهرس 
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Abstract
SUMMARY
D
iuretic treatment of systemic and pulmonary congestion can be ineffective in some patients with HF – a condition commonly referred to as diuretic resistance or refractoriness (Voors et al., 2014).
In the current study, we addressed the problem of diuretic resistance. We have been trying to highlight the impact of electrolyte status (mainly serum sodium and chloride) on diuretic effect of furosemide in patients with chronic heart failure.
This work was a prospective descriptive study which included 30 patients with congenital left to right shunts and chronic heart failure on long term Furosemide therapy presenting with criteria of decompensated heart failure necessitating an increase in diuretic therapy as a decongestive measure. The study was conducted at Ain Shams University Children’s Hospital during the period from June 2018 till March 2019.
All patients were subjected to, full history taking, general clinical assessment and local cardiac examination. Chest X Ray (CXR) with details of Cardiothoracic ratio(CTR) as well as radiological evidence of pulmonary plethora or oedema, Echocardiographic examination with localization of defects,assessment of their sizes and estimation of ejection fraction. Laboratory investigations including serum BUN, Creatinine, Sodium, Potassium and Chloride, Urinary Sodium and Potassium at presentation and at day 3 post treatment.
Regarding demographic data, median age was 0.75 years (range 0.42-1.2 years) with 18 (60%) males and 12 (40%) females, with a male-to- female ratio 1.5:1. Median duration of illness was 6.5 months.
Anthropometric measures of the involved patients showed that mean weight at presentation was 5.64 +/- 2.74 kg, mean BMI 13.39 +/- 4.21 and mean height was 69.13 +/- 16.66 cm.
Regarding clinical data of the included patients, all patients were normotensive with high respiratory rate. Half of the patients had a prolonged capillary refill time › 3 second (53.3%) while 63.3% of the patients were in ROSS class IV. All clinical parameters showed significant improvement on day 3 of therapy.
Regarding radiological parameters of the affected patients, mean CTR was 0.55 +/-0.03 with the majority of patients showing moderate pulmonary congestion (56.7%). These parameters showed significant improvement on day 3.
Labs including serum Sodium, Chloride, Potasssium, bicarbonate and serum PH showed no significant change on day 3 when compared to values obtained at day 1.
Regarding renal and urinary parameters of the patients, BUN and serum creatinine showed significant decrease on day 3 of admission (p value 0.001 and 0.021 significantly). Urinary output and urinary Na showed significant increase (p value =0.00) yet urinary Na/K ratio did not differ significantly.
Patients who were on a high dose furosemide on admission (›3mg/kg/d) with poor response were put on furosemide infusion.
Assuming the need for furosemide infusion as some form of refractoriness to furosemide therapy, we divided the patients into two groups based on their need for furosemide infusion during the acute decompensation.
Studying patients characteristics in each group we found no significant difference in patients clinical data except for the capillary refill time which was significantly longer in patients on furosemide infusion both at presentation and on follow up along with worse Ross classification in that group. Furthermore, patients on furosemide infusion had significantly higher CTR on X ray with no significant change on follow up indicating the need for more time to control congestion.
Comparing laboratory data between the two groups, the only significant difference was found in serum chloride which was significantly lower in the furosemide infusion group both on presentation(p=0.009) and on day 3 (p=0.033)
Surprisingly, patients on furosemide infusion had significantly lower urinary output (UOP)/40 mg furosemide on day 3 of admission (p=0.000).Those patients had also decreased urinary Na/K ratio, required higher diuretic dose and had significantly lower decrease in body weight per 40 mg furosemide. All those parameters point out to diuretic resistance in this group.
Dividing the patients into two groups based on serum chloride, we have found no significant difference in their demographic, anthropometric, clinical or radiological data. The only differentiating point was the need for higher diuretic dose in patients with hypochloremia. Furosemide infusion was needed in 75% of hypocholermic patients versus 22.2% in normochloremic group.There was a linear correlation between serum chloride and dose of Furosemide, Change in Body Weight /total diuretic dose and Netfluid output/40mg frusemide.
For the laboratory data in the two groups, the presence of hypochloremia was not associated with any significant change in serum or urinary electrolytes yet patients with hypochloremia had significantly lower net fluid output/ 40 mg furosemide(p=0.000)
Comparing diuretic response in the two groups, we have found that hypocholermic patients had poorer response to furosemide with decreased Na/K ratio, higher furosemide dose and lower change in body weight/ 40 mg furosemide(p=0.006, 0.000, and 0.000 respectively).
Considering possible correlation between serum Chloride and serum Sodium, we have divided the patients based on serum Na level at presentation to hyponatremia versus normonatremic patients. Hyponatremia was evident in almost half of the patients on presentation (53%).
In our study, patients with hyponatremia did not show different characteristics than those with normal Na level regarding their demographic, anthropometric, clinical or radiological features. Also, serum electrolytes did not differ significantly between the two groups.
The significant difference was found in the urinary electrolytes on day 3 of admission, with significantly higher urinary Na, lower urinary K and a markedly higher Na/K ratio on day 3 of admission in hyponatremic patients (p=0.042, 0.007, 0.000 respectively). Though these changes are suggestive of better natruresis and consequently better diuretic response, yet patients with hyponatremia did not show significant change neither in Na/K ratio nor in cumulative dose of furosemide used or change in bodyweight/ 40 mg frusemide.
Interestingly, comparing patients with hyponatremia, hypochloremia and combined hyponatraemia and hypochloremia we have found that the latter group had the least urinary Na/ K ratio, lowest change in BW and fluid output per 40 mg furosemide denoting highest furosemide resistance in this group