A personalized, multi-ionic approach integrating chloride, potassium, magnesium, and acid-base status offers a more effective framework for managing diuretic resistance in heart failure.
Does a physiology-guided, multi-ionic strategy improve diuretic response in heart failure patients with diuretic resistance compared to escalating diuretic doses?
Patients with heart failure and cardiorenal syndrome experiencing diuretic resistance
Physiology-guided, multi-ionic strategy focused on identifying and correcting biochemical drivers of resistance (chloride, potassium, magnesium, and acid-base status)
Traditional escalation of diuretic doses
Restoration of diuretic response and effective decongestion
Diuretic resistance in heart failure may be better managed by correcting underlying multi-ionic disturbances (chloride, potassium, magnesium, acid-base) rather than simply escalating diuretic doses.
Abstract Background Diuretic resistance in heart failure and the cardiorenal syndrome is traditionally managed by escalating diuretic doses, yet this approach often fails to address the underlying pathophysiology. Summary Emerging evidence challenges the sodium-centred paradigm and identifies chloride as a key determinant of diuretic responsiveness, tightly interconnected with potassium, magnesium, and acid–base balance. Disturbances in this multi-ionic network promote maladaptive tubular responses, neurohormonal activation, and persistent sodium retention, ultimately leading to diuretic resistance. Clinical and mechanistic data consistently show that hypochloraemia, often accompanied by hypokalaemia and metabolic alkalosis, is associated with impaired natriuretic efficiency and worse outcomes. Through a representative clinical case, we illustrate how a physiology-guided, multi-ionic strategy—focused on identifying and correcting the specific biochemical drivers of resistance rather than intensifying diuretics—can restore diuretic response and achieve effective decongestion. Conclusion Diuretic resistance should not be viewed as a failure of dose, but as a failure of understanding. A personalized, multi-ionic approach that integrates chloride, potassium, magnesium, and acid–base status offers a more coherent and effective framework for managing congestion in heart failure.
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Montomoli et al. (Tue,) conducted a review in Diuretic resistance in heart failure and cardiorenal syndrome. Physiology-guided, multi-ionic strategy vs. Escalating diuretic doses was evaluated. A personalized, multi-ionic approach integrating chloride, potassium, magnesium, and acid-base status offers a more effective framework for managing diuretic resistance in heart failure.
www.synapsesocial.com/papers/69fd7ef7bfa21ec5bbf074de — DOI: https://doi.org/10.1093/ckj/sfag119
Marco Montomoli
Maria Inês Roxo
Miguel González-Rico
Clinical Kidney Journal
Universitat de València
Hospital Clínico Universitario de Valencia
INCLIVA Health Research Institute
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