Eric Klug Fluid Overload Congestion is a primary cause of worsening heart failure and HF hospitalisation Residual congestion at the time of discharge is a strong predictor of poor clinical outcomes and hospital readmission ID: 1045445
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1. Management of congestion in heart failureEric Klug
2. Fluid OverloadCongestion is a primary cause of worsening heart failure and HF hospitalisationResidual congestion at the time of discharge is a strong predictor of poor clinical outcomes and hospital readmissionDiuretic therapy targets the intravascular space, allowing lymphatics to drain the interstitial space
3. Underappreciated risk for hospitalization/deathlinked to residual congestion in HFpnts
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5. Diuretics only class I recommended therapy for all HF classes
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7. Mohammad Sarraf et al. CJASN 2009;4:2013-2026
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9. HF induces an increased renal sodium reabsorption,especially in the proximal parts
10. Thirst
11. OAT and the PCTRBFPharmacokineticsUse of dugs that impair diuretic responsiveness (NSAIDS)Diuretics have a significant binding to albumin, and thus a limited amount is freely filteredDecreased diuretic secretion into the tubular lumen results from decreased renal perfusion Loop diuretics are highly (≥95%) protein bound; consequently, they primarily enter the tubular lumen by secretion by the proximal tubule, not by glomerular filtrationLoop diuretics must enter the tubular fluid in order to exert their diuretic effect
12. Benefit from a supine postureDiuretic responsiveness can be influenced by posture, although the effects of posture have not been specifically studied in patients with refractory oedema (better outcomes, improved renal perfusion and presumably urinary diuretic delivery with supine position)Supine position associated with improved creatinine clearance, diuretic response and lower plasma norepinephrine, renin, and aldosterone
13. SaltA very low sodium diet is associated with worse outcomes, and may lead to hyponatremia and hypochloraemia, which may themselves be responsible for the diuretic resistance. Furthermore, a chronic low sodium diet may lead to a sodium, calcium and magnesium depletion within the extracellular matrix and the bones, with resulting osteoporosisHFSA. J Card Fail 2010;16:475-539.Ponikowski P, et al. Eur Heart J 2016;18(8):891-975.
14. Loop diuretics
15. Awaited August, 2022
16. IV THERAPY The initial dose of IV loop diuretic should be approximately 2 or 2.5 times the patient's total maintenance daily oral dose
17. N Engl J Med 2017;377:1964-75
18. Diuretic resistanceDiuretic resistance may be overcome by:Increasing doses of loop diureticAdding second and third diuretics from different classesAlmeshari K, et al. J Am Soc Nephrol 1993;3(12):1878-1883.Rudy DW, et al. Ann Intern Med 1991;115(5):360-366.
19. Combining different diureticsDiuretic synergyKidney International 1991: 39:336-352Sequential nephron blockade with different diuretics
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22. The Fantastic Four of Heart Failure Therapy:A tailored approachPotential for worsening renal functionCirc Heart Fail. 2008;1:2-5.
23. Management of refractory oedema in HF Fluid restrictionAim for 1 to 1.5L/dayAvoid drugs that may interfere with diuretic responsivenessDaily weight diaryShould be performed at the same time each day, usually in the morning, prior to eating and after voidingPatient education and reporting of adverse events
24. Stepped care strategy for decongestion in HF
25. Eur Heart J. 2019 Nov 21;40(44):3605-3612
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27. EMPULSE: Haemoconcentration*
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29. The Fantastic Four of Heart Failure Therapy:A tailored approachSubcutaneous furosemide – the future?
30. ConclusionRemaining congestion carries a worse prognosis in HFThe HF kidney is sodium and water avidThirst needs management, rest/supine position helps initially with diuresis, salt limitation not preferredTubular secretion of loop diuretics required and be aware of offending organic acids/other drugs competing No proven difference in efficacy of various loop diuretics (await TRANSFORM)Chronic diuretic therapy may require increased doses, increased frequency of dose and combinations (Thiazide, CA inhibitor- await ADVOR), and change in route of administration (IV or Subcut)Renal dysfunction may be a consequenceSGLT2 inhibitors decongest, reduce loop diuretic doses, preserve the kidney
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