What is the appropriate management for an 88-year-old patient with stage 4 Chronic Kidney Disease (CKD) and Congestive Heart Failure (CHF) exacerbation, who presents with increased fatigue, Shortness of Breath (SOB), and weight gain after discharge on torsemide (Generic name: torsemide), a loop diuretic?

From the Guidelines

This patient needs immediate medical attention for worsening heart failure despite recent hospitalization, and I recommend increasing the torsemide back to 60 mg daily rather than decreasing to 40 mg as planned, as suggested by the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The 5-pound weight gain, increased shortness of breath, and fatigue strongly suggest fluid retention and heart failure decompensation. Laboratory tests should be obtained to check renal function, electrolytes (particularly potassium), and BNP levels. The patient's stage 4 CKD complicates management, as aggressive diuresis can worsen kidney function, but the heart failure symptoms take priority, as stated in the 2009 focused update incorporated into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults 1. Some key points to consider in the management of this patient include:

• The use of loop diuretics, such as torsemide, in the treatment of heart failure, with the goal of eliminating clinical evidence of fluid retention 1.
• The importance of monitoring the patient's weight, renal function, and electrolytes, and adjusting the diuretic dose as needed to maintain an active diuresis and prevent the recurrence of volume overload 1.
• The potential for diuretic resistance, which can be overcome by escalating the loop diuretic dose, using intravenous administration of diuretics, or combining different diuretic classes 1. If the patient cannot be seen immediately, they should be instructed to:
• Weigh themselves daily
• Restrict fluid intake to 1.5-2 liters daily
• Maintain a low-sodium diet
• Call immediately for worsening symptoms like increased shortness of breath, orthopnea, or edema. The underlying issue may be inadequate diuresis during hospitalization, medication non-adherence, excessive sodium intake, or worsening cardiac function requiring additional heart failure therapies beyond diuretics.

From the FDA Drug Label

1.1 Edema Torsemide tablets are indicated for the treatment of edema associated with heart failure, renal disease or hepatic disease. The patient's symptoms of increased fatigue, SOB, and 5 lb weight gain since discharge may indicate that the current dose of 60 mg of torsemide is not effectively managing the patient's edema associated with heart failure.

• The patient's stage 4 CKD and CHF exacerbation suggest that close monitoring of the patient's condition and adjustment of the torsemide dose as needed is crucial.
• It is essential to assess the patient's renal function and blood pressure to determine the best course of action.
• The patient's treatment plan should be re-evaluated, and the torsemide dose may need to be adjusted to achieve optimal diuretic effect and manage the patient's symptoms effectively 2.

From the Research

Patient Presentation

The patient is an 88-year-old with stage 4 Chronic Kidney Disease (CKD) who presents with increased fatigue, shortness of breath (SOB), and a 5-pound weight gain since discharge 2 days ago. The patient was discharged on 60 mg of torsemide, a loop diuretic, with plans to decrease the dose to 40 mg after 1 week.

Relevant Studies

• The study 3 suggests that metolazone, a thiazide-like diuretic, can be effective in treating refractory heart failure, especially when used in combination with a loop diuretic. The study found that low-dose metolazone (<5 mg) improved NYHA functional class and reduced weight, blood pressure, and plasma sodium and potassium levels.
• The study 4 investigated the effects of adding torasemide to standard therapy in patients with compensated left ventricular systolic dysfunction. The results showed that torasemide did not significantly improve peak oxygen consumption, natriuretic peptides, or quality of life compared to placebo.
• The study 5 analyzed data from the National Hospital Ambulatory Medical Care Survey and found that congestive heart failure was the most common diagnosis in patients aged 80 and over who presented with dyspnea.

Potential Causes of Symptoms

• The patient's symptoms of increased fatigue, SOB, and weight gain may be indicative of congestive heart failure (CHF) exacerbation, which is consistent with the study 5.
• The patient's CKD may also be contributing to their symptoms, as CKD can increase the risk of CHF and fluid overload.
• The use of torsemide, a loop diuretic, may be effective in reducing fluid overload and improving symptoms, but the study 4 suggests that its effects may be limited in patients with compensated left ventricular systolic dysfunction.

Key Points to Consider

• The patient's symptoms and medical history suggest that CHF exacerbation may be a potential cause of their symptoms.
• The use of metolazone, as suggested by the study 3, may be considered as an adjunctive therapy to torsemide to improve diuresis and reduce symptoms.
• Close monitoring of the patient's renal function, electrolyte levels, and fluid status is crucial to avoid potential complications associated with diuretic therapy.