From the Guidelines
For a patient with BUN 33 mg/dL, creatinine 1.53 mg/dL, and an ejection fraction (EF) of 40%, I recommend withholding MRA and considering reducing the dose of ACE inhibitor/ARB, as well as careful monitoring of blood chemistry, according to the ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012 1. To address the patient's condition, it is essential to consider the following steps:
- Check for hypovolaemia/dehydration and exclude the use of other nephrotoxic agents, such as NSAIDs and trimethoprim, as recommended by the ESC guidelines 1.
- If the patient is using concomitant loop and thiazide diuretic, consider stopping the thiazide diuretic to minimize further renal impairment.
- Careful fluid management is crucial, and the patient should be advised to restrict sodium intake to 2-3 g/day and fluid intake to 1.5-2 L/day.
- The patient's heart failure medications, including ACE inhibitors or ARBs, beta-blockers, and potentially mineralocorticoid receptor antagonists, should be optimized under the guidance of a cardiologist, taking into account the patient's renal function and EF.
- Diuretics like furosemide may be needed for volume overload, but their use should be cautious and monitored closely due to the patient's renal dysfunction.
- Regular monitoring of renal function, electrolytes, and volume status with laboratory tests every 1-2 weeks initially is vital to adjust the treatment plan as needed. The patient's condition, with both kidney dysfunction and heart failure with reduced ejection fraction, suggests a cardiorenal syndrome, where the heart and kidney diseases can exacerbate each other 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Patient Assessment
- The patient has been prescribed bumetanide (Bun) 33 mg, which is equivalent to furosemide 40 mg, and has an ejection fraction (EF) of 40% 2, 3, 4.
- The patient's EF is classified as heart failure with reduced ejection fraction (HFrEF) 2, 5.
Treatment Considerations
- Loop diuretics, such as bumetanide and furosemide, are commonly used to treat congestion in patients with HFrEF 3, 4.
- Higher doses of loop diuretics may limit the uptitration of angiotensin-converting enzyme inhibitors (ACEi) and are associated with a higher risk of death and/or heart failure hospitalization 4.
- The use of loop diuretics, particularly at higher doses, may be a marker of increased risk of adverse outcomes in patients with HFrEF 6.
Clinical Outcomes
- Patients with HFrEF who receive higher doses of loop diuretics may experience increased rates of heart failure hospitalizations, emergency department visits, and home health visits 3.
- The adjusted 30-day mortality rate is significantly higher among patients with heart failure with preserved ejection fraction (HFpEF) compared to those with HFrEF 5.
- The use of loop diuretics is strongly associated with heart failure trial-relevant outcomes, including cardiovascular death and heart failure hospitalization 6.