What is the management of diuresis in heart failure with Chronic Kidney Disease (CKD)?

From the Guidelines

Diuresis in heart failure with chronic kidney disease (CKD) should be managed with loop diuretics as the first line of treatment, with furosemide being the preferred choice, starting at 20-40mg IV twice daily or 40-80mg oral daily, with dose adjustments based on response, as recommended by the 2022 AHA/ACC/HFSA guideline 1.

Key Considerations

• Loop diuretics are the mainstay of treatment for diuresis in heart failure with CKD.
• Furosemide is the preferred loop diuretic, with a starting dose of 20-40mg IV twice daily or 40-80mg oral daily.
• Dose adjustments should be made based on the patient's response to treatment.
• For resistant cases, a thiazide-like diuretic such as metolazone can be added to enhance diuretic effect through sequential nephron blockade, as suggested by the 2019 ACC/AHA guidelines comparison 1.
• Spironolactone can be added at low doses if potassium levels allow.
• Continuous IV furosemide infusion may be more effective than bolus dosing in severe cases.

Monitoring and Adjustments

• Daily weight monitoring and fluid restriction to 1.5-2L daily are essential.
• Target a gradual weight loss of 0.5-1kg daily to avoid rapid fluid shifts.
• Monitor renal function, electrolytes, and blood pressure daily during active diuresis, accepting a modest rise in creatinine (up to 30%) as long as the patient is improving clinically, as recommended by the 2016 ESC guidelines 1.
• Adjust diuretic doses and combinations as needed to achieve optimal fluid removal while preserving kidney function.

Rationale

• Loop diuretics reach their site of action through active secretion in the proximal tubule, which remains functional even in CKD.
• The combination with thiazides prevents distal tubule compensatory sodium reabsorption.
• This approach is supported by the 2009 ACCF/AHA heart failure guidelines, which emphasize the importance of diuresis in managing heart failure and the need for careful monitoring and adjustments to achieve optimal outcomes 1.

From the FDA Drug Label

PRECAUTIONS General: Excessive diuresis may cause dehydration and blood volume reduction with circulatory collapse and possibly vascular thrombosis and embolism, particularly in elderly patients.

In patients with severe edema accompanying cardiac failure or renal disease, a low-salt syndrome may be produced, especially with hot weather and a low-salt diet.

Azotemia, presumably prerenal azotemia, may be precipitated during the administration of metolazone tablets, USP If azotemia and oliguria worsen during treatment of patients with severe renal disease, metolazone tablets, USP, should be discontinued.

Use caution when administering metolazone tablets, USP, to patients with severely impaired renal function. As most of the drug is excreted by the renal route, accumulation may occur

Diuresis in Heart Failure with CKD:

• Caution is advised when using diuretics like furosemide and metolazone in patients with heart failure and chronic kidney disease (CKD) due to the risk of excessive diuresis, dehydration, and electrolyte imbalance.
• Monitoring of serum electrolytes, creatinine, and BUN is crucial, especially in the first few months of therapy and periodically thereafter.
• Adjustments to diuretic doses and other medications may be necessary to avoid adverse effects.
• Renal function should be closely monitored, and diuretics should be used with caution in patients with severely impaired renal function 2 3.

From the Research

Diuretic Therapy in Heart Failure with CKD

• Diuretic therapy is a crucial component in the management of heart failure, especially in patients with chronic kidney disease (CKD) 4, 5, 6, 7, 8.
• The use of loop diuretics is common in heart failure management, but some patients may exhibit fluid overload despite high doses of loop diuretics 5.
• Combination diuretic therapy, such as the addition of a thiazide-type diuretic to loop diuretics, can induce diuresis in patients resistant to high doses of loop diuretics 5, 7.
• However, combination diuretic therapy can also increase the risk of severe hypokalemia, hyponatremia, hypotension, and worsening renal function 5, 7.

Benefits and Risks of Diuretic Therapy in CKD

• High-dose and combination diuretic therapy may be necessary in patients with CKD, but it can be complicated by worsening kidney function and electrolyte imbalances 4.
• The benefits of renin-angiotensin-aldosterone axis inhibitor therapy in patients with mild-to-moderate CKD have been demonstrated, but such therapy is not used in all suitable patients due to fear of hyperkalemia and worsening kidney function 4.
• Sodium-glucose cotransporter inhibitor therapy has been shown to improve mortality and hospitalization in patients with heart failure and CKD stages 3 and 4 4, 8.

Clinical Considerations

• A multidisciplinary approach, including combined cardiology-nephrology clinics, may be necessary for the implementation of evidence-based therapy in patients with heart failure and CKD 4, 6, 8.
• Physicians should be aware of the potential benefits and risks of diuretic therapy in patients with CKD and carefully monitor patients for signs of worsening kidney function and electrolyte imbalances 5, 7.
• The use of novel drugs, such as angiotensin receptor blocker neprilysin inhibitors and sodium glucose linked transporters 2 inhibitors, may offer a new perspective in patients with CKD 8.