What is the appropriate treatment for bilateral leg edema due to congestive heart failure or chronic kidney disease in an 84‑year‑old woman?

Treatment of Bilateral Leg Swelling in an 84-Year-Old Woman with Heart Failure or CKD

Loop diuretics, specifically furosemide, are the cornerstone of treatment for bilateral leg edema in this patient, regardless of whether the underlying cause is heart failure or chronic kidney disease, as they provide the most rapid symptomatic relief and are the only agents that can adequately control fluid retention in both conditions. 1, 2

Primary Treatment Approach

Loop Diuretics as First-Line Therapy

• Furosemide is FDA-approved and indicated for edema associated with congestive heart failure, cirrhosis, and renal disease including nephrotic syndrome, making it appropriate for both suspected etiologies in this patient 2

• Loop diuretics produce symptomatic benefits more rapidly than any other drug class, relieving pulmonary and peripheral edema within hours to days 1

• Loop diuretics maintain efficacy even when renal function is severely impaired, unlike thiazide diuretics which lose effectiveness when creatinine clearance falls below 40 mL/min 1

• Start with low doses and titrate upward until urine output increases and weight decreases by 0.5 to 1.0 kg daily 1

• Consider twice-daily dosing or dose escalation if initial response is inadequate 1

• Alternative loop diuretics like torsemide may be considered if furosemide response is suboptimal, due to superior absorption and longer duration of action 1

Critical Management Principles

Diuretics should never be used as monotherapy in heart failure, even when successful at controlling symptoms 1. The 2025 American Journal of Kidney Diseases guidelines emphasize that optimal decongestion must occur in tandem with guideline-directed medical therapies to reduce adverse outcomes 1

Key Monitoring Parameters:

• Assess adequacy of natriuresis and decongestion through daily weights, physical examination for jugular venous distension, peripheral edema, and pulmonary congestion 1

• Monitor for venous congestion as the primary driver of worsening kidney function in heart failure, rather than assuming low cardiac output 1

• Watch for diuretic-related complications: electrolyte imbalances, volume depletion, and falls—particularly dangerous in elderly patients 3

• Avoid inappropriately high diuretic doses that cause volume contraction, which increases risk of hypotension and renal insufficiency 1

Addressing the Underlying Etiology

If Heart Failure is Confirmed:

• Combine diuretics with ACE inhibitors (or ARBs) and beta-blockers as guideline-directed medical therapy to reduce mortality, hospitalizations, and kidney function decline 1

• These agents improve quality of life and modify disease trajectory, but require weeks to months for clinical effects to become apparent (unlike diuretics) 1

• Diuretics are essential for the success of other heart failure medications—inadequate diuresis diminishes ACE inhibitor response and increases beta-blocker risk 1

If Chronic Kidney Disease is the Primary Cause:

• Loop diuretics remain the preferred agent as they maintain efficacy in severe renal impairment 1

• ACE inhibitors or ARBs can be used cautiously for blood pressure control in unilateral renal artery stenosis 1

• In bilateral severe renal artery stenosis or single functioning kidney, ACE inhibitors/ARBs may be considered only if well-tolerated and under close monitoring 1

• Calcium channel blockers, beta-blockers, and diuretics are recommended for hypertension management in renal artery disease 1

Diagnostic Considerations Before Treatment

While treatment should not be delayed, the following help confirm the diagnosis:

• Elevated BNP/NT-proBNP strongly suggests heart failure and warrants echocardiography 4, 5

• Echocardiography is essential to assess ejection fraction, diastolic function, and pulmonary artery pressure 1, 5

• Urinalysis for proteinuria helps identify nephrotic syndrome or other renal causes 4, 5

• In patients ≥45 years with bilateral leg edema, cardiopulmonary pathology (including pulmonary hypertension) is frequently missed when clinicians assume venous insufficiency 6

Common Pitfalls to Avoid

• Do not prescribe diuretics empirically without determining the underlying cause—this leads to long-term inappropriate use with serious complications in elderly patients 3

• Do not use thiazide diuretics as primary therapy when renal function is impaired (creatinine clearance <40 mL/min) 1

• Do not use diuretics alone for heart failure management—this fails to maintain long-term clinical stability 1

• Avoid assuming low cardiac output is causing kidney dysfunction in heart failure; venous congestion is the dominant mechanism in most patients 1

• Do not overlook medication-induced edema (calcium channel blockers, NSAIDs) as a contributing factor 3, 7

Treatment Algorithm Summary

1. Initiate loop diuretics immediately for symptomatic relief 1, 2
2. Titrate dose based on daily weight loss (0.5-1.0 kg/day) and clinical decongestion 1
3. If heart failure confirmed: Add ACE inhibitor/ARB and beta-blocker as tolerated 1
4. If CKD is primary cause: Continue loop diuretics, add antihypertensives as needed (ACE-I/ARB with caution if bilateral disease) 1
5. Monitor closely for electrolyte disturbances, volume depletion, and changes in renal function 1, 3
6. Reassess frequently—inadequate decongestion worsens outcomes in both heart failure and kidney disease 1