What are the next steps for an elderly woman with right-sided congestive heart failure (CHF), peripheral edema, and venous stasis, on furosemide (Lasix) 120 mg twice daily (bid), with impaired renal function and an estimated glomerular filtration rate (GFR) of 25, who refuses an echocardiogram (ECHO) and compression stockings?

Management of Right-Sided CHF with Advanced Renal Impairment

Given this patient's severe renal impairment (GFR 25), high-dose furosemide requirement, and refusal of key diagnostic/therapeutic interventions, the priority is aggressive diuretic optimization with close monitoring for worsening renal function, while continuing to educate about the critical importance of echocardiography to guide therapy. 1, 2

Immediate Diuretic Optimization

The current furosemide dose of 120 mg BID (240 mg/day total) is appropriate for severe heart failure with GFR 25, but requires conversion to intravenous administration if oral therapy is failing. 2, 3

• Switch to IV furosemide if persistent volume overload exists, as intestinal edema in heart failure causes unpredictable oral absorption and reduced bioavailability 2, 4
• Loop diuretics require substantially higher doses when GFR <30 mL/min due to impaired tubular secretion 5, 3
• Target net fluid loss of 2-3 liters over 48-72 hours with daily weights and strict intake/output monitoring 2
• Consider adding metolazone 2.5-5 mg daily for synergistic diuresis if loop diuretic resistance develops, as sequential nephron blockade can restore diuretic responsiveness 1

Critical Monitoring Parameters

Monitor renal function and electrolytes daily during active diuresis—checking serum creatinine, BUN, potassium, and sodium. 2, 3

• Urine sodium <50 mmol/L or urine sodium-to-furosemide ratio <2 mmol/mg predicts inadequate decongestion and is associated with worsening renal function and poor long-term outcomes 6
• Small creatinine increases (up to 0.3 mg/dL) during appropriate decongestion are acceptable and often reversible, but creatinine >2.5 mg/dL or potassium >5.5 mmol/L requires dose adjustment 5, 3
• Worsening renal function during hospitalization is associated with increased long-term mortality, so avoid excessive diuresis causing prerenal azotemia 2, 5

Addressing Refusal of Echocardiography

Without echocardiography, you cannot distinguish right-sided CHF from biventricular failure, pulmonary hypertension, or valvular disease—each requiring different management strategies. 1

• Strongly counsel the patient that echocardiography is non-invasive, takes 20-30 minutes, and is essential to determine if she needs additional life-saving medications (beta-blockers, ACE inhibitors/ARBs, aldosterone antagonists, or SGLT2 inhibitors) 1
• Consider measuring BNP or NT-proBNP to assess heart failure severity and guide therapy intensity, though this doesn't replace echocardiography 1, 7
• If isolated right-sided failure is confirmed, evaluate for pulmonary hypertension, chronic lung disease, or tricuspid regurgitation as underlying causes 1

Neurohormonal Antagonist Optimization

If the patient has any component of left ventricular dysfunction (which you cannot know without echo), she is missing critical mortality-reducing therapies. 1

• ACE inhibitors or ARBs should be continued or initiated unless contraindicated, as they provide mortality benefit even with GFR 25, though close monitoring is required 5, 3
• Beta-blockers (carvedilol, metoprolol succinate, or bisoprolol) reduce mortality in heart failure and should be titrated gradually over weeks to months 2, 5
• Aldosterone antagonists (spironolactone 12.5-25 mg daily) provide additional mortality benefit in NYHA class III-IV heart failure, but require potassium <5.0 mmol/L and creatinine <2.5 mg/dL 2, 5
• SGLT2 inhibitors (dapagliflozin 10 mg or empagliflozin 10 mg daily) provide mortality benefit and can be used down to GFR 20 mL/min 5, 7

Managing Compression Stocking Refusal

Compression stockings are secondary to achieving euvolemia with diuretics—focus on aggressive decongestion first. 1

• Educate that venous stasis and peripheral edema will persist without mechanical support once euvolemia is achieved 1
• Leg elevation and sodium restriction (<2 grams daily) are alternative strategies if compression stockings are refused 1, 7
• Persistent edema despite adequate diuresis may indicate venous insufficiency rather than heart failure, requiring different management 1

Consideration of Advanced Therapies

If diuretic resistance develops despite combination therapy, ultrafiltration may be necessary to achieve adequate fluid removal. 1, 8

• Ultrafiltration is indicated for diuretic-resistant heart failure and can restore responsiveness to conventional diuretic doses 1, 8
• This requires hospitalization and close monitoring, but reduces hospitalization rates and diuretic requirements at 6 months 8
• Worsening renal function occurs in approximately 14% of ultrafiltration cases, so reserve for truly refractory patients 8

Common Pitfalls to Avoid

• Do not discontinue loop diuretics for modest creatinine increases during appropriate decongestion, as this leads to persistent volume overload and worse outcomes 1, 5
• Avoid thiazide diuretics as monotherapy in this patient with GFR 25, as they are ineffective at this level of renal function 5, 7
• Do not use NSAIDs or COX-2 inhibitors, as they worsen heart failure and increase hospitalization risk 1, 3
• Monitor for hyperkalemia closely if combining aldosterone antagonists with ACE inhibitors/ARBs in elderly patients with renal impairment 2, 5
• Ensure patient is not discharged until a stable diuretic regimen is established and ideally euvolemia is achieved, as premature discharge leads to early readmission 1