What is the recommended fluid intake for a patient with Chronic Kidney Disease (CKD) and heart failure with an Ejection Fraction (EF) of 45%?

Fluid Intake Recommendations for CKD Patients with Heart Failure (EF 45%)

For a patient with CKD and heart failure with an ejection fraction of 45% (HFmrEF), fluid restriction to 1.5-2 L/day should only be implemented if the patient has severe symptoms with congestion; routine fluid restriction is not recommended for mild to moderate symptoms. 1, 2

Clinical Assessment Framework

Your patient's EF of 45% classifies them as having heart failure with mildly reduced ejection fraction (HFmrEF) 3. The fluid management strategy depends critically on their current symptom severity and congestion status:

For Patients with Mild to Moderate Symptoms (NYHA Class I-II)

• No routine fluid restriction is recommended - recent evidence shows no benefit and may actually worsen thirst without improving outcomes 1, 2, 4
• If any restriction is considered, use weight-based fluid allowance of 30 mL/kg body weight/day (or 35 mL/kg if body weight >85 kg), which causes less thirst than fixed restrictions 2
• A recent 2025 randomized trial demonstrated that liberal fluid intake versus restriction to 1,500 mL/day showed no difference in health status or safety events, but significantly reduced thirst distress 4

For Patients with Advanced/Severe Heart Failure Symptoms

• Restrict fluids to 1.5-2 L/day to relieve symptoms and congestion 3, 1, 2
• This recommendation from the European Society of Cardiology applies specifically to advanced heart failure with or without hyponatremia 3
• The American College of Cardiology similarly recommends this range only for severe symptoms 1

Special Considerations for CKD

The presence of CKD does not change the fundamental fluid management approach - it remains symptom-driven rather than based on kidney function alone 5. However, important caveats include:

• Monitor for diuretic resistance, which is more common in advanced CKD due to reduced nephron mass and decreased filtered sodium load 3
• CKD patients may require higher diuretic doses or combination diuretic therapy (sequential nephron blockade) to achieve adequate decongestion 3
• Sodium restriction to <2 g/day (or <5 g sodium chloride/day) is recommended for blood pressure and volume control in CKD 1

Monitoring and Patient Education

Daily Weight Monitoring

• Patients must monitor and record daily weight to recognize rapid weight gain 1, 2
• A sudden weight gain >2 kg in 3 days should trigger increased diuretic dose and/or healthcare team notification 1, 2

Signs of Fluid Overload

• Educate patients to recognize and monitor signs of congestion: peripheral edema, orthopnea, paroxysmal nocturnal dyspnea 1, 2
• Teach flexible diuretic therapy adjustment if appropriate 1, 2

Critical Pitfalls to Avoid

• Do not implement extreme salt restriction - establish a lower limit with 3 g/day as a guide, as excessive restriction may be harmful 1
• Avoid salt substitutes with high potassium content in CKD stage 3 patients, especially with eGFR <30 mL/min/1.73 m² or hyperkalemia 1
• Fluid restriction should not be implemented in isolation but as part of comprehensive heart failure management including optimal GDMT 2
• In older adults with frailty or sarcopenia, consider less restrictive fluid management to prevent dehydration 1

Special Circumstances

For Hyponatremia

• Restrict hypotonic fluids to 1.5-2 L/day to improve hyponatremia 1, 2
• Consider sodium restriction to <100 mmol/day (2.3 g/day) in hyponatremic hypervolemic patients 1

For Travel to Hot Climates

• Allow additional 0.5-1.0 L/day of non-alcoholic drinks 1, 2
• Patients should regularly check body weight and adjust diuretics and fluid intake accordingly 2

Evidence Quality Note

The 2024 European Society of Cardiology consensus statement and 2025 randomized trial data have significantly challenged traditional fluid restriction practices 6, 4. The most recent high-quality evidence shows that routine fluid restriction in stable chronic heart failure patients provides no benefit and increases thirst distress without improving outcomes 7, 4.