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Hospital admissions due to heart failure (HF) are common, even more so in patients who also have chronic kidney disease (CKD). These admissions often require intravenous diuretics to treat fluid accumulation. Patients with concomitant HF and CKD (HF-CKD) have a high risk of morbidity and mortality despite diuresis. Hospitalisation is not without its own risks including hospital-acquired infections, reduced quality of life and malnutrition. This service improvement project explored the utility of home delivered subcutaneous furosemide (SCF) to treat fluid overload in HF-CKD patients.
This project was developed as a collaboration between a London hospital trust, a monitoring hub and a community Healthcare NHS Trust hospital-at-home team. Governance was provided by the latter. Patients were included if they had an established diagnosis of HF, eGFR <60ml/min/1.732 and presented haemodynamically stable with fluid overload. Patients were identified in the community, outpatient clinics or the emergency department and were all reviewed by a HF-Kidney specialist and the HF team. Following review, patients were treated in the community with 5 days of SCF delivered via a butterfly needle and infusion pump, at a dose of 80 mg/day over 5 hours. This was administered by the hospital-at-home team in liaison with the hospital specialists with continuous monitoring via the community monitoring hub. Renal function was assessed daily. Following treatment, all patients were reviewed by hospital specialists to assess their response and adjust maintenance medications.
Nine patients (median age 84 (IQR 13), 55.6% male, 55.6% reduced ejection fraction, mean baseline eGFR 32.9±13.7 ml/min/1.732, mean baseline loop diuretic dose 140±60 mg, mean serum albumin 32.9±3.6g/L) completed the treatment (Table 1). Patients continued their oral diuretics; however, doses were occasionally held based on their blood pressure.
All participants avoided hospitalisation during the five-day course of SCF. However, one patient required hospitalisation following his final hospital review due to an increase in body weight (patient 5 in graph 1.) This patient died of sepsis of unknown origin during this admission, 25 days after their final dose of SCF. Two patients were hospitalised with recurrent fluid overload 14 and 4 days respectively, after their final dose of SCF.
Mean final potassium was lower than mean baseline potassium (3.93±0.49 vs 4.3±0.45 mmol/L, p=0.021). Five patients received oral potassium supplements. There was insufficient evidence to suggest that final mean creatinine was different to baseline mean creatinine (170.44(±63.3) vs 171.44(±59.4) µmol/L, p=0.734.)
One patient experienced postural hypotension leading to omission of a dose of SCF. One patient with known arrhythmias was found on monitoring to have asymptomatic ventricular tachyarrhythmia at 184bpm lasting for 30 seconds, requiring ATP to terminate the episode (serum potassium 4.3mmol/L) and later required valvular intervention.
Conclusions
These findings demonstrate that, with primary and secondary care collaboration and monitoring, SCF can be delivered at-home safely in HF-CKD patients with fluid overload to avoid hospital admission and that this model of care is worth pursuing in a larger hypothesis testing trial.