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Diuretic Resistance in Heart Failure

  • Emergency Medicine (F Peacock, Section Editor)
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Abstract

Purpose of Review

Diuretic resistance (DR) occurs along a spectrum of relative severity and contributes to worsening of acute heart failure (AHF) during an inpatient stay. This review gives an overview of mechanisms of DR with a focus on loop diuretics and summarizes the current literature regarding the prognostic value of diuretic efficiency and predictors of natriuretic response in AHF.

Recent Findings

The pharmacokinetics of diuretics are impaired in chronic heart failure, but little is known about mechanisms of DR in AHF. Almost all diuresis after administration of a loop diuretic dose occurs in the first few hours after administration and within-dose DR can develop. Recent studies suggest that DR at the level of the nephron may be more important than defects in diuretic delivery to the tubule. Because loop diuretics induce natriuresis, urine sodium (UNa) concentration may serve as a functional, physiological, and direct measure for diuretic responsiveness to a given loop diuretic dose.

Summary

Identifying and targeting individuals with DR for more aggressive, tailored therapy represents an important opportunity to improve outcomes. A better understanding of the mechanistic underpinnings of DR in AHF is needed to identify additional biomarkers and guide future trials and therapies.

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Authors and Affiliations

  1. Department of Cardiovascular Medicine, Vanderbilt University Medical Center, 1121 Medical Center Dr., Nashville, TN, 37212, USA

    Richa Gupta

  2. Department of Cardiovascular Medicine, Yale Medical Center, PO Box 208017, New Haven, CT, 06520, USA

    Jeffrey Testani

  3. Department of Emergency Medicine, Vanderbilt University Medical Center, 1313 21st Ave. S, 703 Oxford House, Nashville, TN, 37232, USA

    Sean Collins

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  1. Richa Gupta
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Correspondence to Sean Collins.

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Conflict of Interest

Richa Gupta declares no conflicts of interest.

Jeffrey Testani received consultancy fees and/or research grants from AstraZeneca, Boehringer Ingelheim, Sanofi, Abbott, FIRE1, Sequana Medical, Otsuka, Bristol Myers Squibb, Reprieve Medical, Cardionomic, and 3ive labs.

Sean Collins received consultancy fees and/or research grants from Novartis, Vixiar, Ortho Clinical, NIH, AHRQ, PCORI, DOD, AHA, and CREAVO.

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Gupta, R., Testani, J. & Collins, S. Diuretic Resistance in Heart Failure. Curr Heart Fail Rep 16, 57–66 (2019). https://doi.org/10.1007/s11897-019-0424-1

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