Key Points
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The administration of loop diuretics to achieve decongestion is the cornerstone of therapy for acute heart failure
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Impaired diuretic response is a common complication in patients with acute heart failure and is associated with increased rehospitalization and mortality compared with patients who have normal diuretic response
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Impaired absorption, decreased renal blood flow, azotaemia, hypoalbuminaemia, and proteinuria result in reduced levels of active diuretics in the tubular lumen, and diminish diuretic effectiveness
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Several treatment strategies, including increased dose of intravenous loop diuretics, combination therapy, and ultrafiltration, aim to improve biological availability of the drugs and counteract maladaptive responses in diuretic-resistant patients
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Quantitative measures of diuretic response have been proposed, but need to be validated in larger populations of patients with acute heart failure
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An enhanced understanding of diuretic response should ultimately lead to improved individualized approaches to treating patients with acute heart failure
Abstract
The administration of loop diuretics to achieve decongestion is the cornerstone of therapy for acute heart failure. Unfortunately, impaired response to diuretics is common in these patients and associated with adverse outcomes. Diuretic resistance is thought to result from a complex interplay between cardiac and renal dysfunction, and specific renal adaptation and escape mechanisms, such as neurohormonal activation and the braking phenomenon. However, our understanding of diuretic response in patients with acute heart failure is still limited and a uniform definition is lacking. Three objective methods to evaluate diuretic response have been introduced, which all suggest that diuretic response should be determined based on the effect of diuretic dose administered. Several strategies have been proposed to overcome diuretic resistance, including combination therapy and ultrafiltration, but prospective studies in patients who are truly unresponsive to diuretics are lacking. An enhanced understanding of diuretic response should ultimately lead to an improved, individualized approach to treating patients with acute heart failure.
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ter Maaten, J., Valente, M., Damman, K. et al. Diuretic response in acute heart failure—pathophysiology, evaluation, and therapy. Nat Rev Cardiol 12, 184–192 (2015). https://doi.org/10.1038/nrcardio.2014.215
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DOI: https://doi.org/10.1038/nrcardio.2014.215
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