Diuretic-resistant heart failure and the role of ultrafiltration: A proposed protocol

• Published in: Revista portuguesa de cardiologia 2023-09, Vol.42 (9), p.797-803
• Main Authors: Gomes da Silva, Francisca, Calça, Rita, Rita Martins, Ana, Araújo, Inês, Aguiar, Carlos, Fonseca, Cândida, Branco, Patrícia
• Format: Article
• Language: English
• Subjects: Cardiorenal syndrome; Congestão venosa; Diuretic resistance; Diálise peritoneal; Heart failure; Insuficiência cardíaca; Peritoneal dialysis; Resistência a diuréticos; Síndrome cardiorrenal; Venous congestion
• ISSN: 0870-2551; 2174-2030
• DOI: 10.1016/j.repc.2022.05.012

Acute heart failure (HF) decompensation generally manifests with signs and symptoms of congestion that strongly predict poor poor patient outcome. Loop diuretics are the cornerstone of therapy to counteract fluid overload and are widely used for acute management and chronic stabilization of HF. However, a diminished response to loop diuretics is a common problem, affecting the patient's clinical course and potentially prolonging hospitalization. Diuretic resistance is defined as failure to decongest despite appropriate and escalating loop diuretic therapy. We propose a protocol for the management of diuretic resistance. The initial approach should include an assessment of causes of pseudo-diuretic resistance. Adjustments to loop diuretic therapy, such as increasing doses and frequency of administration and sequential nephron blockade, may be successful. For hospitalized patients with progressive disease there are more invasive methods for fluid removal. Switching from oral to intravenous loop diuretics is essential to avoid variable absorption and for symptomatic relief. Extracorporeal ultrafiltration is also an option since this technique is highly effective at removing plasma fluid from blood. While extracorporeal ultrafiltration is an invasive solution, peritoneal dialysis is a home-based, intermittent therapeutic option that can enable efficient management of fluid overload, preventing HF-related hospital admission, and improving quality of life. As a last resort for fluid removal, a peritoneal dialysis regimen should fully exploit its decongestive properties and should be tailored to the patient's characteristics and clinical needs. A insuficiência cardíaca (IC) descompensada manifesta-se por sinais e sintomas de congestão, que são fortes preditores de mau prognóstico. Os diuréticos de ansa são a base do tratamento da sobrecarga hídrica nas descompensações agudas e na estabilização crónica, mas uma resposta diminuída aos mesmos é frequente na IC. Tal afeta o curso clínico e condicionais internamentos mais prolongados. A «resistência a diuréticos» é definida pela incapacidade em tratar sintomas congestivos, apesar da terapêutica adequada e crescente com diuréticos de ansa. Propomos um protocolo de atuação para ultrapassar esta resistência em que a abordagem inicial passa pela exclusão de causas de pseudo-resistência. Estratégias como o aumento da dose ou do número de administrações de diuréticos de ansa, ou o bloqueio sequencial do nefrónio, podem ser