How to manage fluid overload in a dialysis patient with heart failure?

Managing Fluid Overload in Dialysis Patients with Heart Failure

Dialysis patients with heart failure and fluid overload should be promptly treated with intravenous loop diuretics as first-line therapy, with ultrafiltration or peritoneal dialysis reserved for diuretic-resistant cases, while maintaining guideline-directed medical therapy for heart failure throughout treatment. 1

Initial Diuretic Strategy

Intravenous Loop Diuretics

• Start with IV loop diuretics immediately upon recognition of significant fluid overload to reduce morbidity and improve symptoms. 1, 2
• For patients already on oral loop diuretics, the initial IV dose should equal or exceed their chronic oral daily dose, administered as either intermittent boluses or continuous infusion. 1
• Furosemide 20-40 mg IV is the most commonly used agent, though torsemide or bumetanide may provide superior oral bioavailability and longer duration of action in some patients. 1, 3
• In dialysis patients with severely impaired renal function, higher doses of loop diuretics are typically required—doses up to 200 mg daily for torsemide have been studied. 3

Monitoring Parameters

• Measure daily weight at the same time each day, fluid intake/output, vital signs, and clinical signs of congestion (jugular venous pressure, peripheral edema) and systemic perfusion. 1, 2
• Check daily serum electrolytes, blood urea nitrogen, and creatinine during active IV diuretic therapy or medication titration. 1
• Assess urine output serially and adjust diuretic doses accordingly to relieve symptoms and reduce volume excess while avoiding hypotension. 1, 2

Intensification for Inadequate Response

Sequential Nephron Blockade

• When diuresis is inadequate despite appropriate loop diuretic dosing, intensify the regimen by either increasing IV loop diuretic doses or adding a second diuretic with complementary mechanism of action. 1
• Add thiazide-type diuretics (metolazone 2.5-5 mg daily, chlorothiazide, or hydrochlorothiazide) to loop diuretics for patients with refractory edema. 1
• Reserve combination diuretic therapy for patients who do not respond to moderate- or high-dose loop diuretics alone to minimize electrolyte abnormalities. 1
• Consider adding mineralocorticoid receptor antagonists (spironolactone), which provide both diuretic effects and cardiovascular benefits. 1, 4

Alternative Strategies

• Continuous infusion of loop diuretics may overcome diuretic resistance better than intermittent boluses in some patients. 1
• Low-dose dopamine infusion may be considered alongside loop diuretics to improve diuresis and preserve renal blood flow, though evidence is limited. 1

Mechanical Fluid Removal

Ultrafiltration

• Consider ultrafiltration for patients with obvious volume overload who remain unresponsive to aggressive diuretic strategies, including high-dose and combination diuretic therapy. 1, 5
• Ultrafiltration can restore responsiveness to conventional diuretic doses and produce meaningful clinical benefits in diuretic-resistant heart failure. 1, 5
• The combination of diuretic therapy and/or ultrafiltration can achieve volume control in essentially all patients with heart failure. 5

Peritoneal Dialysis

• Peritoneal dialysis should be considered for dialysis-dependent patients with symptomatic fluid overload refractory to conventional therapy, as it improves symptoms and prevents hospital admissions. 4, 6
• This approach is particularly valuable in patients with hemodynamic instability who cannot tolerate hemodialysis. 7, 6

Maintaining Heart Failure Medications

Continuation of Guideline-Directed Medical Therapy

• Continue ACE inhibitors/ARBs/ARNi, beta-blockers, and mineralocorticoid receptor antagonists during hospitalization unless hemodynamic instability or contraindications exist. 1
• Beta-blockers have demonstrated improved outcomes in heart failure patients across all stages of CKD, including those on dialysis. 4
• Initiate beta-blocker therapy only after optimization of volume status and successful discontinuation of IV diuretics, vasodilators, and inotropic agents, starting at low doses in stable patients. 1

Medication Adjustments

• Consider temporary reduction or discontinuation of ACE inhibitors, ARBs, or aldosterone antagonists in patients with significant worsening renal function until improvement occurs. 1
• Avoid withholding or reducing beta-blockers unless the patient was recently started on therapy, has marked volume overload, or has marginal/low cardiac output. 1
• SGLT2 inhibitors improved mortality and hospitalization in heart failure patients with CKD stages 3-4 (eGFR >20 ml/min per 1.73 m²). 4

Critical Pitfalls to Avoid

Premature Discontinuation of Diuresis

• Do not stop diuresis prematurely due to small increases in serum creatinine (elevations around 0.3 mg/dL)—persistent congestion at discharge increases mortality and readmission rates. 1
• Continue diuresis until clinical evidence of fluid retention is eliminated, even if this results in mild-to-moderate decreases in blood pressure or renal function, provided the patient remains asymptomatic. 1
• Excessive concern about hypotension and azotemia leads to underutilization of diuretics and refractory edema. 1

Inadequate Diuretic Dosing

• Inappropriately low diuretic doses result in fluid retention, which diminishes response to ACE inhibitors and increases risk with beta-blocker therapy. 1
• As heart failure advances, declining renal perfusion limits kidney response to diuretics, requiring progressive dose increments. 1

Dietary Sodium and Drug Interactions

• Patients become unresponsive to high-dose diuretics when consuming large amounts of dietary sodium—restrict to 2-3 grams daily. 1
• NSAIDs (including COX-2 inhibitors) block diuretic effects and should be avoided. 1

Discharge Planning

Optimization Before Discharge

• Do not discharge patients until a stable and effective diuretic regimen is established and euvolemia is ideally achieved—unresolved edema increases risk of early readmission. 1
• Include a specific plan for diuretic adjustment in the discharge regimen to decrease rehospitalizations. 1
• Many patients can modify their own diuretic regimen in response to daily weight changes exceeding a predefined range. 1
• Ensure follow-up within 7-14 days and/or telephone follow-up within 3 days of hospital discharge. 2