Systematic review shows UNa-guided diuretic titration increases short-term diuresis in hospitalized acute decompensated heart failure patients

BACKGROUND: Diuretic resistance remains a major challenge in acute decompensated heart failure (ADHF). Urinary sodium (UNa) concentration provides an early marker of loop diuretic responsiveness, yet its clinical utility remains uncertain. METHODS: We conducted a systematic review and meta-analysis (PROSPERO ID: CRD420251175306). PubMed, Embase, Scopus, and CENTRAL were searched from database inception to October 1, 2025, for studies evaluating UNa-guided diuretic titration in hospitalized ADHF patients. Primary outcomes were 24- and 48 h diuresis and natriuresis; secondary outcomes included congestion relief, renal function, length of stay, rehospitalization, and mortality. Data were pooled using random-effects models. Heterogeneity was assessed using I² and χ² statistics. Analyses were performed with the R software (version 4.4.3, meta package). Certainty of evidence was rated using the GRADE framework. RESULTS: Five studies were included (three RCTs, two observational cohorts). UNa-guided therapy significantly increased 24- and 48 h diuresis (MD = 0.59,95%CI [0.30-0.87] L; MD = 0.70 [0.37-1.03] L) and natriuresis (MD = 88 [52-124] mmol; MD = 138 [69-206] mmol; all P < 0.001). No significant differences were observed in mortality (RR = 0.99 [0.60-1.63]), rehospitalization (RR = 0.90 [0.57-1.41]), renal dysfunction, or length of stay. Safety outcomes, including hypotension, hypokalemia, and renal worsening, were similar (all P > 0.05). Certainty of evidence was moderate for natriuresis/diuresis and low for clinical outcomes. CONCLUSIONS: UNa-guided diuretic therapy enhances short-term natriuresis and diuresis without increasing adverse events but shows no proven impact on mortality, rehospitalization, or renal outcomes. Larger studies are needed to confirm its long-term benefit and feasibility.