Successful Conversion From Thiazide to Tolvaptan in a Patient With Stage D Heart Failure and Chronic Kidney Disease Before Heart Transplantation

Abstract

SummaryChronic kidney disease (CKD) is often complicated with advanced heart failure because of not only renal congestion and decreased renal perfusion but also prolonged use of diuretics at higher doses, which sometimes results in hyponatremia. Preoperative CKD is known to be associated with poor prognosis after heart transplantation (HTx). We experienced a stage D heart failure patient with CKD and hyponatremia who was switched from trichlormethiazide to tolvaptan. His hyponatremia was normalized, and his renal function was improved after conversion to tolvaptan. In patients with stage D heart failure, it may be useful to administer tolvaptan with a concomitant reduction in the dose of diuretics in order to preserve renal function and avoid hyponatremia before HTx. (Int Heart J 2013; 54: 48-50) Key words: Hyponatremia, Diuretics, Renal dysfunction C hronic kidney disease (CKD) and hypervolemic hyponatremia are often complicated with advanced heart failure, and are not only attributable to renal congestion and reduced renal perfusion but also to extended use of diuretics at higher doses.1-5) Heart transplantation (HTx) is the comprehensive solution for patients with stage D heart failure refractory to optimal medical therapy thus far, 6) but it is well known that preoperative CKD results in a poor prognosis after HTx.7) It is especially important to preserve preoperative renal function since postoperative immunosuppressive therapy cannot help some kinds of renal impairment. 8) We experienced a stage D heart failure patient with CKD who was administered tolvaptan (TLV) and a vasopressin type 2 (V2) receptor antagonist, along with discontinuation of trichlormethiazide. His hyponatremia normalized and his renal function improved. Furthermore, his renal function remained within an acceptable range after HTx under immunosuppressive therapy including a calcineurin inhibitor. Case ReportThe patient was a 53-year-old male with ischemic cardiomyopathy (Figure 1, Table) who had received coronary artery bypass surgery in March 2010. His heart failure worsened even after the bypass surgery, and he eventually became dependent on intravenous infusion of inotropes regardless of maximum medical therapy including carvedilol, enalapril, spironolactone, trichlormethiazide, and furosemide in August 2010. He was transferred to our hospital as a possible candidate for HTx in September 2010. His laboratory data on admission showed 137 mEq/L of serum sodium, 1.9 mg/dL of serum total bilirubin, 1.2 mg/dL of serum creatinine, and 636 pg/mL of plasma B-type natriuretic peptide. Transthoracic echocardiography indicated an ejection fraction of 28% and left ventricular diastolic diameter of 67 mm. A hemodynamic study performed in December 2010 demonstrated that mean right atrial pressure was 2 mmHg, mean pulmonary capillary wedge pressure was 21 mmHg, and the cardiac index was 2.2 L/minute/m 2 under continuous infusion of inotropes. He was then listed in February 2011 as a recipient of HTx. In the meantime, his serum creatinine increased...

Tolvaptan Prolongs Blockage of the Vasopressin Type II Receptor Over 24 Hours in Responders With Stage D Heart Failure

“…[1][2][3][4][5][6][7][8][9][10] In contrast, we sometimes experience TLV-non-responders in our daily clinical practice. 11) We previously proposed a novel predictor of responsiveness to TLV, ie, the baseline urine aquaporin-2 (U-AQP2) level relative to the plasma AVP (P-AVP) level, which may indicate a preserved vasopressin type 2 receptor (V2R)-related signaling pathway in the principal cells of the renal collecting duct.…”

Urine Sodium Excretion After Tolvaptan Administration Is Dependent Upon Baseline Serum Sodium Levels

“…[3][4][5][6][7] We also reported the effi cacy and safety of TLV in (1) amelioration of congestion even in stage D HF patients and (2) improvement of renal function by converting ongoing diuretics to TLV. 8,9) With respect to serum sodium concentration (S-Na), various studies in Europe and the United States have demonstrated the effi cacy of TLV to improve hyponatremia with little chance of hypernatremia, ie, S-Na > 145 mEq/L (eg, 1.7% of hypernatremia in the EVEREST study and 0% in the QUEST study). 2,6,[10][11][12] In Japan, we can administer TLV to HF patients to treat their congestion regardless of baseline S-Na as long as hypernatremia or rapid increases in S-Na do not develop.…”

Tolvaptan Can Improve Clinical Course in Responders

“…Therefore, longer administration of TLV under reduced doses of conventional diuretics may be necessary for signifi cant reversal in renal function as well as normalization of serum sodium concentration, as was observed in our previous case. 10) We acknowledge that our study has several limitations. First, it was conducted retrospectively in a single center, and consequently included a limited number of patients and may have patient selection bias.…”

“…8) We also reported cases in which TLV could improve hyponatremia and/or renal function without compromise of hemodynamics in patients with stage D HF. 9,10) However, TLV is sometimes ineffective in a certain number of patients with HF, but the definition of a good response to TLV has not yet been established. 3,11) We have used the defi nition of "responders" as patients with any increase in urine volume (UV) at day 1 when we started TLV administration, and proposed novel criteria consisting of 2 parameters on urine osmolality (U-OSM) that could predict responsiveness to TLV in decompensated HF patients.…”