Current Heart Failure Reports

, Volume 16, Issue 2, pp 57–66 | Cite as

Diuretic Resistance in Heart Failure

  • Richa Gupta
  • Jeffrey Testani
  • Sean CollinsEmail author
Emergency Medicine (F Peacock, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Emergency Medicine


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.


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.


Acute heart failure Loop diuretics Diuretic resistance Spot urine sodium Biomarkers 


Compliance with Ethical Standards

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.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

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© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Cardiovascular MedicineVanderbilt University Medical CenterNashvilleUSA
  2. 2.Department of Cardiovascular MedicineYale Medical CenterNew HavenUSA
  3. 3.Department of Emergency MedicineVanderbilt University Medical CenterNashvilleUSA

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