Renal function and decongestion with acetazolamide in acute decompensated heart failure: the ADVOR trial.
A pre-specified analysis of the ADVOR trial showed that adding acetazolamide to loop diuretics improves decongestion in acute decompensated heart failure across the full range of kidney function, and that the more frequent worsening of renal function it causes is transient and not linked to worse clinical outcomes.
Background
Acetazolamide improved decongestion in the ADVOR trial, but clinicians worry about its renal effects, especially in patients who already have impaired kidney function. This analysis examined whether the benefit holds across renal function and how acetazolamide affects kidney function.
Study design
Pre-specified analysis of the ADVOR trial (519 patients with acute decompensated heart failure and volume overload, median baseline eGFR 40 ml/min/1.73 m²) randomized to intravenous acetazolamide or placebo on top of intravenous loop diuretics. Decongestion, diuresis, natriuresis, clinical outcomes, and changes in renal function were assessed by baseline eGFR.
Key findings
Acetazolamide consistently increased the likelihood of decongestion across the entire eGFR spectrum (P-interaction 0.977), with greater natriuresis and diuresis in patients with lower eGFR. Worsening renal function (creatinine rise ≥0.3 mg/dL) was more frequent with acetazolamide during treatment (40.5% vs 18.9%; P<0.001), but creatinine did not differ at 3 months and this was not associated with more heart-failure hospitalizations or death. Successful decongestion at discharge predicted better outcomes regardless of whether worsening renal function occurred.
Clinical implications
Acetazolamide is effective for decongestion even in patients with reduced kidney function, and the transient creatinine rise it causes should not deter its use — achieving decongestion, not avoiding a temporary eGFR dip, is what correlates with better outcomes.
Category
Research
Source
European Heart Journal
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