The Use of Tolvaptan to Prevent Renal Dysfunction in High Risk Patients With Heart Failure-Pilot Study

Inclusion Criteria:

• ≥ 18 years old
• Prior clinical diagnosis of systolic heart failure (EF < 40% within the past 18 months) with daily home use of oral loop diuretic for at least one month.
• Daily oral dose of furosemide ≥ 40 mg and ≤ 240 mg (or equivalent)
• Identified within 24 hours of hospital admission
• Heart failure defined by at least 1 symptom (dyspnea, orthopnea, or edema) AND 1 sign (rales on auscultation, peripheral edema, ascites, pulmonary vascular congestion on chest radiography)
• Anticipated need for IV loop diuretics for at least 48 hours
• Likely requires daily net urine output in the range of 1-3 L/day for over a 72-96 hour time period.
• Albumin level < 3.5 g/dL
• Willingness to provide informed consent

Exclusion Criteria:

• Received or planned IV vasoactive treatment (inotropes, vasodilators) or ultra-filtration therapy for heart failure
• BNP < 250 ng/ml or NT-proBNP < 1000 mg/ml (if drawn for clinical purposes)
• Systolic BP < 90 mmHg
• Serum creatinine > 3.0 mg/dl at baseline or renal replacement therapy or creatinine clearances < 10 mL/min
• Serum sodium > 145 mEq/L
• Acute coronary syndrome within 4 weeks
• Anticipated need for coronary angiography or other procedures requiring IV contrast.
• Patients receiving any of the following drugs: clarithromycin, ketoconazole, itraconazole,ritonavir, indinavir, nelfinavir, saquinavir, nefazodone, telithromycin, erythromycin, fluconazole, aprepitant, diltiazem, verapamil, cyclosporine, and grapefruit juice.
• Pregnant or nursing patients.