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Diuretic resistance
1. Challenging Cases in Acute Heart Failure
Diuretic Resistance
Kevin Damman, MD, PhD
University Medical Center Groningen
Groningen, The Netherlands
k.damman@umcg.nl
3. Scope of the Problem
• Acute (Decompensated) Heart Failure patient
• Treatment with conventional methods:
i.v. Loop Diuretics
Oxygen, morfine if necessary, vasodilators
Either:
No improvement in symptoms/signs or worsening
No increase in diuresis
Increase in serum creatinine
Diuretic Resistance?
5. Definition
No Consensus on definition of Diuretic Resistance
• “Poor response to diuretic therapy”
• Peristent signs and symptoms despite diuretic therapy
• Furosemide > 80mg daily (chronic HF)
• Fractional Sodium excretion < 0.2%
• Failure to excrete at least 90 mmol of sodium within 72h of a 160
mg oral furosemide dose given twice daily
• Lack of weight loss during i.v. loop diuretic therapy
• Lack of negative fluid balance during i.v. Loop diuretic therapy
6. Diuretic Response
No Consensus on definition of Diuretic Resistance
• It might be better to speak of the relative response to diuretics
Diuretic Response
Diuretic Efficacy
• Overcomes the problem of estalishing a ‘cut off’
• Highlights the importance of response to diuretics on a continuous
scale
7. Weight Change
Adapted from Fonarow et al Rev Cardiovasc Med 2003 (ADHERE)
Little / no weight
loss or weight
increase
~50%
16. Diuretic Resistance and WRF
Increase in serum creatinine ≠ Diuretic Resistance
• Worsening Renal Function (WRF) occurs frequently in AHF
• WRF not always associated with poor outcome:
Pseudo WRF during adequate decongestion
Valente et al Eur Heart J 2014 (PROTECT)
17. Treatment
Most importantly: Identify patients experiencing poor diuretic
response early
If using only oral loop diuretics:
Dose appropriately (eGFR)
Consider changing loop diuretic:
Furosemide Bumetanide -> Torsemide
Add Thiazide
Add Mineralocorticoid receptor antagonist
Switch to intravenous loop diuretic
18. Treatment
Intravenous Loop Diuretics:
• Furosemide
be aware of albumin levels
consider switch to Bumetanide/Torsemide
• Dose properly: High dose in patients with low eGFR