Article Type : Review Article
Authors : Degirmenci H, Bakirci EM and Hamur H
Keywords : Heart failure; Morbidity; Mortality; Diuretic resistance; Diagnosis; Treatment
Diuretics are one of
the main drugs for heart failure, which is the leading cause of morbidity and
mortality. It contributes to the reduction of symptoms and hospitalizations.
However, diuretic resistance is seen in 20-30% of patients with heart failure.
Various parameters such as weight loss, congestion status, urine output, urine
sodium excretion are evaluated in determining diuretic resistance. Treatments
such as restriction of salt and fluid intake, discontinuation of non-steroidal
anti-inflammatory drugs, increasing diuretic dose and frequency, combination of
diuretics from different classes, hypertonic saline infusion or dopamine
infusion are used in diuretic resistance.
Heart failure is seen in 1% of patients over 65
years old. Heart failure is one of the leading causes of morbidity and
mortality. Diuretics are among the main drugs used in this disease with high
morbidity and mortality rates [1,2]. However, 20-30% of patients with heart
failure have diuretic resistance. Diuretics reduce congestion and reduce
hospitalizations. Therefore, we present the current approach to diuretic
resistance in heart failure in this article.
Low systemic blood pressure, high blood urea
nitrogen, ischemic heart failure and diabetes are predictors of diuretic
resistance. Diuretics are ineffective in case of venous edema, lymphatic edema,
and shifting of the intravascular volume to the third space. No sodium and
fluid restriction, hepatic cirrhosis, hypoalbunemia, nephrotic syndrome,
insufficient absorption, insufficient dosage of the drug, low frequency of drug
intake, drug no adherence, decreased diuretic secretion, insufficient kidney to
the drug, use of non-steroidal anti-inflammatory drugs, increased renin
angiotensin aldosterone system activation causes diuretic resistance [3].
1 mg bumetanide, 20 mg torsemide and 40 mg furosemide
are equivalent. Congestion persists despite using furosemide over 80 mg, weight
change < 2.7 kg despite 40 mg furosemide or equivalent diuretic, urine
output < 1400 ml / day despite using 40 mg furosemide or equivalent
diuretic, fractional excretion of sodium in basal < 0.2%, a urinary sodium
concentration / urinary furosemide concentration ratio of < 2 mmol / mg or a
urinary sodium amount of < 90 mmol despite 160 mg furosemide twice in 3 days
is defined as diuretic resistance [4,5].
Initial
measures
Daily sodium intake should be below 100 mEq/day.
Nonsteroidal anti-inflammatory therapy should be discontinued. The frequency
and dosage of loop diuretics should be increased [5-7]. In hospitalized
patients, 80 mg intravenous loop diuretic or intravenous loop diuretic is
started at 2.5 times the oral dose at home. Urine sodium strategy (emergency
pathway) for evaluating the diuretic response or urine output strategy
(established pathway) can be used. Spot urine sodium is checked 1-2 hours after
the diuretic is started in the emergency pathway. If urine sodium is >50-70
mmol / l, urine sodium assessment is repeated after each dose. Current doses
are repeated every 6-12 hours [7]. In the established pathway, urine output is
evaluated 2-6 hours after the diuretic is started. If the urine output is above
150 ml / hour, the current doses are repeated every 6-12 hours. If spot urine
sodium is <50-70 mmol / l or urine output is <150 ml / hour, twice the
previous dose is administered intravenous loop diuretic. In insufficient
diuretic response, up to 300 mg of furosemide and equivalent loop diuretics are
repeated. Combination therapy is started in case of insufficient diuretic
response. The first choice in combination therapy is to add a thiazide diuretic
to the loop diuretic. The second preference in combination therapy is to add
acetazolamide, amiloride or sprinolactone to the loop diuretic.
Hypertonic saline infusion improves diuresis and
renal function while shortening hospitalization. The addition of dopamine
infusion to low dose intravenous furosemide provides urine output similar to
high dose diuretic [5-7].