Steroid sensitive nephrotic syndrome (SSNS) is one of the most common chronic kidney diseases in children. These guidelines update the existing Indian Society of Pediatric Nephrology recommendations on its management. To frame revised guidelines on diagnosis, evaluation, management and supportive care of patients with the illness. The guidelines combine evidence-based recommendations and expert opinion. Formulation of key questions was followed by review of literature and evaluation of evidence by experts in two face-to-face meetings. The initial statements provide advice for evaluation at onset and follow up and indications for kidney biopsy. Subsequent statements provide recommendations for management of the first episode of illness and of disease relapses. Recommendations on the use of immunosuppressive strategies in patients with frequent relapses and steroid dependence are accompanied by suggestions for step-wise approach and plan of monitoring. Guidance is also provided regarding the management of common complications including edema, hypovolemia and serious infections. Advice on immunization and transition of care is given. The revised guideline is intended to improve the management and outcomes of patients with SSNS, and provide directions for future research.

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Steroid Sensitive Nephrotic Syndrome: Revised Guidelines

Heart failure (HF) is a significant cause of morbidity, mortality, and decreased quality of life (QOL). Symptoms, including reduced activity tolerance, fatigue, palpitations, and dyspnea, result from volume overload or low output states. Herein, we review the best available literature supporting diuretic and inotropic therapies in advanced HF and how these improve QOL. While diuretics and inotropes reduce symptoms and hospitalizations in advanced HF, there is an increased risk of harms with both modalities. While diuretic complications include electrolyte and renal function abnormalities, adverse event data with inotropes is more complex and includes possible arrhythmias and death. Further, inotrope utilization is complicated by required intravenous access, infusion costs, and limited outpatient support. Ambulatory use of diuretics and inotropes may improve patients’ QOL through symptom management and reduced hospitalizations. However, risks and limitations of both modalities must be considered as treatment decisions are made.

Home Therapies in Advanced Heart Failure: Inotropes and Diuretics

Author(s): Dixit, Neal M; Shah, Shivani; Ziaeian, Boback; Fonarow, Gregg C; Hsu, Jeffrey J | Abstract: Heart failure remains a huge societal concern despite medical advancement, with an annual direct cost of over $30 billion. While guideline-directed medical therapy (GDMT) is proven to reduce morbidity and mortality, many eligible patients with heart failure with reduced ejection fraction (HFrEF) are not receiving one or more of the recommended medications, often due to suboptimal initiation and titration in the outpatient setting. Hospitalization serves as a key point to initiate and titrate GDMT. Four evidence-based therapies have clinical benefit within 30 days of initiation and form a crucial foundation for HFrEF therapy: renin-angiotensin-aldosterone system inhibitors with or without a neprilysin inhibitor, β-blockers, mineralocorticoid-receptor-antagonists, and sodium-glucose cotransporter-2 inhibitors. The authors present a practical guide for the implementation of these four pillars of GDMT during a hospitalization for acute heart failure.

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Optimizing Guideline-directed Medical Therapies for Heart Failure with Reduced Ejection Fraction During Hospitalization

Refractory congestion is common in acute and chronic heart failure, and it significantly impacts functional class, renal function, hospital admissions, and survival. In this paper, the pathophysiological mechanisms involved in cardiorenal syndrome and the interplay between heart failure and chronic kidney disease are reviewed. Although the physical exam remains key in identifying congestion, new tools such as biomarkers or lung, vascular, and renal ultrasound are currently being used to detect subclinical forms and can potentially impact its management. Thus, an integrated multimodal diagnostic algorithm is proposed. There are several strategies for treating congestion, although data on their efficacy are scarce and have not been validated. Herein, we review the optimal use and monitorization of different diuretic types, administration route, dose titration using urinary volume and natriuresis, and a sequential diuretic scheme to achieve a multitargeted nephron blockade, common adverse events, and how to manage them. In addition, we discuss alternative strategies such as subcutaneous furosemide, hypertonic saline, and albumin infusions and the available evidence of their role in congestion management. We also discuss the use of extracorporeal therapies, such as ultrafiltration, peritoneal dialysis, or conventional hemodialysis, in patients with normal or impaired renal function. This review results from a multidisciplinary view involving both nephrologists and cardiologists.

/pdf/multimodal-strategies-for-the-diagnosis-and-management-of-1wacx4ge.pdf

Multimodal Strategies for the Diagnosis and Management of Refractory Congestion. An Integrated Cardiorenal Approach

Management of heart failure in cardiac amyloidosis using an ambulatory diuresis clinic.

While torsemide's oral bioavailability and half-life theoretically render it a more efficient diuretic than furosemide, the clinical outcomes of torsemide compared with furosemide remain unclear. We performed a systematic review and meta-analysis, including all published studies that compared torsemide and furosemide use in heart failure patients from January 1996 through August 2019. Nineteen studies (9 randomized control trials (RCTs) and 10 observational studies) with a total of 19,280 patients were included. During a mean follow-up duration of 15 months, torsemide was associated with a numerically lower risk of hospitalization due to heart failure (10.6% vs. 18.4%; odds ratio (OR) 0.72, 95% confidence interval (CI) (0.51, 1.03), p=0.07, I2=18%; number needed to treat (NNT) =23) compared with furosemide. Torsemide was associated with statistically significant more improvement in functional status from New York Heart Association (NYHA) class III/IV to I/II (72.5% vs. 58%; OR 2.32, 95% CI (1.32, 4.1), p=0.004, I2=27%; NNT=5) and lower risk of cardiac mortality (1.5% vs. 4.4%; OR 0.37, 95% CI (0.20, 0.66), p

Joel Topf

Papers

Meta-Analysis Comparing Torsemide Versus Furosemide in Patients With Heart Failure.