There is no author summary for this article yet. Authors can add summaries to their articles on ScienceOpen to make them more accessible to a non-specialist audience.
Abstract
Treatment of congestive heart failure has changed dramatically during the past 20
years, but diuretic drugs remain an essential component. Diuretics are essential despite
the fact that these drugs stimulate the renin-angiotensin-aldosterone (RAA) axis and
lead to adaptive responses that may be counterproductive. In this paper, new diuretic
drugs and new uses of older drugs are discussed. These approaches emphasize low-dose
combination therapy and may prove superior to traditional approaches that rely exclusively
on loop diuretics. Such approaches aim to prevent adverse compensatory processes that
appear to result from chronic diuretic treatment. These include acute and chronic
increases in plasma renin activity and stimulation of the sympathetic nervous system,
both of which increase afterload and may tend to increase mortality. They also include
adaptive changes in nephron structure and function resulting from diuretic-induced
increases in distal sodium load and diuretic-induced neurohormonal stimulation. These
adaptations blunt the effectiveness of diuretic therapy. Diuretic strategies that
rely on combinations of diuretics are emphasized as a method to prevent resistance.
If diuretic resistance does develop, higher-dose combination regimens, continuous
diuretic infusions and mechanical ultrafiltration can be used to overcome diuretic
adaptations and restore diuretic efficacy. The goal of reducing the extracellular
fluid volume with the least stimulation of the RAA axis and minimal changes in nephron
architecture can be achieved in many patients.