Treatment of Hepatic Congestion in Congestive Heart Failure
Intravenous loop diuretics are the primary treatment for hepatic congestion in patients with congestive heart failure (CHF), as they provide the most rapid and effective treatment for signs and symptoms of congestion. 1
Initial Management of Hepatic Congestion
- Patients with CHF and hepatic congestion should be promptly treated with intravenous loop diuretics (furosemide, torsemide) to improve symptoms and reduce morbidity 1, 2
- The FDA specifically indicates that intravenous furosemide is appropriate "when a rapid onset of diuresis is desired" in patients with congestive heart failure 2
- Diuretic therapy should be titrated with the goal to completely resolve clinical evidence of congestion before discharge to reduce symptoms and rehospitalizations 1
- Monitoring during diuresis should include careful measurement of fluid intake and output, vital signs, daily standing body weight, and clinical signs of congestion 1
Optimizing Diuretic Therapy
When diuresis is inadequate to relieve hepatic congestion and other symptoms, it is reasonable to intensify the diuretic regimen using either: 1
- Higher doses of intravenous loop diuretics
- Addition of a second diuretic (such as a thiazide)
For patients with refractory congestion, ultrafiltration is a reasonable option when they are not responding to aggressive medical therapy 1, 3
Parenteral therapy should be replaced with oral furosemide as soon as practical 2, 4
Addressing the Underlying Cardiac Dysfunction
While diuretics provide symptomatic relief, they do not correct the underlying pathophysiological mechanisms of hepatic congestion in CHF 1, 5
After initial decongestion, therapy should focus on implementation and up-titration of guideline-directed medical therapy (GDMT) including: 1
- ACE inhibitors or ARBs
- Beta-blockers
- Mineralocorticoid receptor antagonists (MRAs)
- SGLT-2 inhibitors
The lowest possible dose of diuretics should be used to facilitate up-titration of GDMT and mitigate the risk of diuretic-related complications 1
Monitoring Hepatic Function
Patients with hepatic congestion due to CHF may present with elevated liver enzymes, direct and indirect serum bilirubin due to passive congestion 5, 6
Chronic passive congestion can lead to sinusoidal hypertension, centrilobular fibrosis, and eventually cardiac cirrhosis after several decades of ongoing injury 7
Daily laboratory tests during active medication adjustment should include serum electrolytes, urea nitrogen, and creatinine concentrations 1
Pitfalls and Caveats
Diuresis should not be discontinued prematurely because of small changes in serum creatinine, as elevations in the range of 0.3 mg/dL do not necessarily indicate significant renal dysfunction 1, 8
Evidence of persistent congestion at discharge has been reported in 25-50% of patients, who have higher rates of mortality and readmission 1
In patients with hepatic congestion due to CHF, the total clearance of medications like torsemide may be approximately 50% of that seen in healthy volunteers due to reduced hepatic and renal clearance 9
The discharge regimen should include a plan for adjustment of diuretics to decrease rehospitalizations 1