A 2018 overview of diuretic resistance in heart failure | Revista Portuguesa de Cardiologia (English edition)

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Jardim, Luís Ramos dos Santos, Inês Araújo, Filipa Marques, Patrícia Branco, Augusta Gaspar, Cândida Fonseca" "autores" => array:7 [ 0 => array:4 [ "nombre" => "Sofia Isabel" "apellidos" => "Jardim" "email" => array:1 [ 0 => "sofiaisabeljardim@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Luís" "apellidos" => "Ramos dos Santos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Inês" "apellidos" => "Araújo" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 3 => array:3 [ "nombre" => "Filipa" "apellidos" => "Marques" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "d" "identificador" => 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Medicina III, Hospital São Francisco Xavier, Lisbon, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Serviço de Nefrologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "A resistência aos diuréticos na insuficiência cardíaca revisitada em 2018" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1943 "Ancho" => 2583 "Tamanyo" => 340799 ] ] "descripcion" => array:1 [ "en" => "Pathophysiology-based approach to diuretic resistance." ] ] ] "textoCompleto" => "IntroductionThe incidence of heart failure (HF) is 1% among American patients over 65 years of age.<a class="elsevierStyleCrossRefs" href="#bib0285">1,2</a> Portuguese figures from the 2002 Epidemiologia da Insuficiência Cardiaca e Aprendizagem (EPICA) study concluded that the overall prevalence of HF is 4.4%, peaking at 16% in those over 80 years of age.<a class="elsevierStyleCrossRef" href="#bib0295">3</a> It continues to be the primary discharge diagnosis among elderly American patients.<a class="elsevierStyleCrossRef" href="#bib0300">4</a> Hospitalization for HF constitutes an ominous sign, with half of patients readmitted in the subsequent six months and a mortality rate of 25-35% at the end of the first year.<a class="elsevierStyleCrossRefs" href="#bib0300">4,5</a> Consequently, HF is a high burden disease with elevated direct and indirect costs.<a class="elsevierStyleCrossRef" href="#bib0285">1</a>Current treatment includes drugs that alter disease progression such as angiotensin converting enzyme inhibitors, angiotensin II receptor blockers or, more recently, sacubitril/valsartan, beta-blockers and mineralocorticoid receptor antagonists – in HF with reduced ejection fraction – and drugs used to improve symptoms such as diuretics, namely loop diuretics.<a class="elsevierStyleCrossRefs" href="#bib0310">6–8</a> Loop diuretics are the cornerstone of congestion relief and are widely used for acute management (up to 90% of patients) as well as for chronic stabilization.<a class="elsevierStyleCrossRefs" href="#bib0290">2,5,8–10</a>Despite the fact that diuretics themselves are not linked to increased survival,<a class="elsevierStyleCrossRefs" href="#bib0310">6,8</a> diuretic efficacy has been shown to prolong event-free survival, regardless of glomerular filtration rate.<a class="elsevierStyleCrossRefs" href="#bib0305">5,11–13</a>In this review, we discuss the underlying pathophysiology of diuretic resistance in HF patients, while providing several currently available evidence-based pharmacological and non-pharmacological strategies to overcome this problem (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). The aim of this article is to summarize the existing data and highlight recent research on the subject, providing an up-to-date and practical approach to diuretic resistance.<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Diuretic resistance – defining the problemThere is ample variation in the definition of diuretic-resistant patients.<a class="elsevierStyleCrossRef" href="#bib0345">13</a> The general definition refers to the failure to achieve effective congestion relief despite appropriate or escalating doses of diuretics.<a class="elsevierStyleCrossRefs" href="#bib0350">14,15</a>Some early reports estimated the prevalence of diuretic resistance to be 20-30% among HF patients.<a class="elsevierStyleCrossRefs" href="#bib0360">16,17</a> However, the lack of a formal definition makes it impossible to properly assess the numbers.<a class="elsevierStyleCrossRefs" href="#bib0325">9,13,15</a>Recent data link furosemide-equivalent doses of loop diuretics (for intravenous diuretics, 1 mg of bumetanide, 20 mg of torsemide and 40 mg of furosemide<a class="elsevierStyleCrossRef" href="#bib0335">11</a>) to changes in several parameters such as weight loss, urine output or natriuresis as means to diagnose diuretic resistance.<a class="elsevierStyleCrossRef" href="#bib0345">13</a> These studies are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>Depending on the study, poor diuretic response may be defined as: a weight change of 0 to 2.7 kg per 40 mg of furosemide (or equivalent)<a class="elsevierStyleCrossRef" href="#bib0370">18</a>; a urinary diuretic response <1400 ml per 40 mg of furosemide (or equivalent)<a class="elsevierStyleCrossRef" href="#bib0370">18</a>; a fractional excretion of sodium at baseline <0.2%<a class="elsevierStyleCrossRef" href="#bib0375">19</a>; a urinary sodium concentration and urinary furosemide concentration ratio (both obtained from spot urine samples) <2 mmol/mg<a class="elsevierStyleCrossRef" href="#bib0340">12</a>; and/or lower chloride levels at baseline (97 to 103 mEq/l).<a class="elsevierStyleCrossRef" href="#bib0380">20</a> However, the correlation between different metrics remains poor and there is no cut-off to establish actual diuretic resistance.<a class="elsevierStyleCrossRef" href="#bib0345">13</a> Prospective trials are needed to properly validate these metrics.<a class="elsevierStyleCrossRef" href="#bib0385">21</a>Predictors of diuretic resistance, on the other hand, are more firmly established between studies and include: low systemic blood pressure, elevated blood urea nitrogen, HF of ischemic origin and diabetes.<a class="elsevierStyleCrossRefs" href="#bib0305">5,11,18,22</a> These studies also found that diuretic resistance is an independent predictor of worse in-hospital outcomes for HF, early post-discharge mortality and increased HF rehospitalization.Pharmacokinetics & pharmacodynamics of loop diureticsThe relationship between loop diuretic concentration and natriuresis can be illustrated through an S-shaped dose-response curve,<a class="elsevierStyleCrossRef" href="#bib0350">14</a> which means that a minimal concentration must be reached at the site of action before any response is noted.<a class="elsevierStyleCrossRef" href="#bib0320">8</a> A normal dose-response relationship can be distorted by a variety of clinical conditions. In HF patients, the curve is shifted downwards and to the right, which translates into a decreased maximal diuretic response.<a class="elsevierStyleCrossRef" href="#bib0320">8</a> Furthermore, during hospitalization, diuretic response is affected by many individual factors<a class="elsevierStyleCrossRef" href="#bib0350">14</a> including, but not limited to, renal failure, which also shifts the curve to the right, meaning a higher dose of diuretics is needed to achieve the same degree of natriuresis.<a class="elsevierStyleCrossRef" href="#bib0320">8</a>Pathophysiology of diuretic resistanceThe pathophysiology of diuretic resistance is complex and several causes may be involved (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<a class="elsevierStyleCrossRef" href="#bib0355">15</a> It stems from multiple factors, including reduced delivery of the diuretic to its luminal site of action, neurohormonal activation, tubular compensatory adaptation and drug interactions.<a class="elsevierStyleCrossRef" href="#bib0355">15</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>Reduced delivery of the diuretic to its site of actionReduced delivery of the diuretic to its site of action is closely related to its decreased bioavailability.In HF patients, increased peripheral and bowel wall edema leads to reduced absorption of the diuretic, with a more marked effect when oral furosemide is used.<a class="elsevierStyleCrossRef" href="#bib0385">21</a>HF itself as well as concurrent chronic kidney disease (CKD) (urate and other competing organic acids) may lead to decreased glomerular filtration rate, which in turns leads to impaired secretion of diuretics (namely furosemide) by the organic acid transporter into the proximal tubule. Reduced glomerular filtration rate can, therefore, reduce delivery or reduce active secretion of loop diuretics into their site of action.<a class="elsevierStyleCrossRef" href="#bib0395">23</a> Moreover, CKD has been proposed as a contributing factor to the development of HF overall, regardless of left ventricular ejection fraction. CKD leads to volume retention, altered calcium–phosphate metabolism, hyperparathyroidism, vitamin D deficiency, anemia, and the accumulation of uremic toxins.<a class="elsevierStyleCrossRef" href="#bib0400">24</a> Renal dysfunction caused by intra-abdominal hypertension and cardiorenal syndrome are also plausible mechanisms of diuretic resistance through venous congestion.<a class="elsevierStyleCrossRefs" href="#bib0325">9,25</a> Intra-abdominal hypertension relief improves renal perfusion, renal filtration and diuresis. It is usually present in up to 60% of acutely decompensated HF patients.<a class="elsevierStyleCrossRef" href="#bib0405">25</a> It is very important to emphasize the need to detect third-space overload as opposed to intravascular overload because both the kidneys and diuretic therapy can only act in vascular overload. Persistent diuretic use in patients who are already suffering from intravascular volume depletion further activates the renin-angiotensin-aldosterone (RAA) axis and makes diuretic resistance dependent on renal blood flow. Urinary sodium and chloride measurements may indicate when vascular volume has been optimized because they decrease as euvolemia approaches.<a class="elsevierStyleCrossRef" href="#bib0345">13</a> These may serve as more reliable markers of decongestion as opposed to the clinical signs and symptoms traditionally used to guide decongestive therapy.<a class="elsevierStyleCrossRef" href="#bib0410">26</a> Clinical signs and symptoms lack sensitivity and specificity but do raise the need for further clinical evaluation. Natriuretic peptides are helpful for diagnosis and prognosis but lack the power to properly monitor volume status.<a class="elsevierStyleCrossRef" href="#bib0410">26</a> Newer approaches point to quantitative blood volume analysis as means to differentiate hypervolemia profiles. Appropriate profiling of volume overload in HF, according to blood volume, has therapeutic implications and may aid patients with diuretic resistance, redirecting them to other forms of decongestion.<a class="elsevierStyleCrossRef" href="#bib0410">26</a>Another mechanism of diuretic activity impairment involves increased re-absorption of sodium and chloride in the proximal tubule, leading to decreased delivery of these substrates to the distal areas of the nephron where loop diuretics act. This mechanism causes diuretic resistance through decreased substrate availability to the sodium-potassium-chloride cotransport system.<a class="elsevierStyleCrossRef" href="#bib0345">13</a>Albumin levels also correlate to diuretic action because they are high affinity albumin-binding molecules (>90%).<a class="elsevierStyleCrossRef" href="#bib0325">9</a> Hypoalbuminemia increases the drug distribution volume and prevents suitable kidney delivery. On the other hand, high levels of albuminuria decrease loop diuretic delivery. Increased urine albumin binds to diuretics, preventing their ligation to the sodium-potassium-chloride receptors and thus impairing their action.<a class="elsevierStyleCrossRef" href="#bib0325">9</a>Neurohormonal activationNeurohormonal activation is strongly related to RAA axis upregulation. Loop diuretics can activate the RAA axis through a variety of mechanisms.<a class="elsevierStyleCrossRef" href="#bib0355">15</a> They induce renin secretion through the direct blockade of the macula densa sodium-potassium-chloride cotransport system, thus leading to increased renin and aldosterone in a volume-independent pathway.<a class="elsevierStyleCrossRef" href="#bib0320">8</a> Furthermore, diuretics induce renal prostacyclin production, which increases renin secretion. Finally, diuretics induce volume contraction, thus activating renin secretion through vascular stimulation.<a class="elsevierStyleCrossRef" href="#bib0320">8</a> RAA axis activation eventually leads to increased sodium reabsorption, prompting the onset of post-diuretic sodium retention and the braking phenomenon.<a class="elsevierStyleCrossRef" href="#bib0355">15</a> Post-diuretic sodium retention is one of the processes through which diuretic resistance may be established and it arises as soon as the concentration of diuretic in the tubular fluid drops below the therapeutic threshold.<a class="elsevierStyleCrossRef" href="#bib0355">15</a> A negative net sodium balance in the 24 hours between natriuresis and post-diuretic sodium retention may not be achieved in the event of dietary noncompliance, rendering the diuretic effect insignificant.<a class="elsevierStyleCrossRef" href="#bib0355">15</a> The braking phenomenon, on the other hand, is defined as the decrease in diuresis volume after multiple same-dose administrations of diuretic. This is linked to RAA axis activation and compensatory changes in the nephron.<a class="elsevierStyleCrossRef" href="#bib0325">9</a>Tubular compensatory readaptationTubular readaptation is another mechanism that helps explain reduced diuretic response.<a class="elsevierStyleCrossRef" href="#bib0385">21</a> Owing to the abovementioned activation of the RAA axis, as well as the braking phenomenon, proximal tubular reabsorption arises, leading to increased sodium uptake in this area of the nephron.<a class="elsevierStyleCrossRef" href="#bib0385">21</a> Simultaneously, the chronic use of loop diuretics – which inhibit sodium uptake in the loop of Henle – leads to increased sodium delivery to the distal tubular system, resulting in compensatory hyperplasia and hypertrophy.<a class="elsevierStyleCrossRef" href="#bib0325">9</a> This means that the patient would retain more sodium and thus water than a diuretic-naïve patient.<a class="elsevierStyleCrossRefs" href="#bib0345">13,21</a> This resistance mechanism can be overcome using a sequential nephron blockade with thiazide diuretics.<a class="elsevierStyleCrossRef" href="#bib0325">9</a>Drug interactionsSome drugs, such as nonsteroidal anti-inflammatory drugs (NSAIDs), can reduce the effect of diuretics.<a class="elsevierStyleCrossRef" href="#bib0385">21</a>NSAIDs may cause diuretic resistance in a number of ways, particularly: decreased prostaglandin synthesis, decreased renal vasodilation, increased renal reabsorption in areas of the nephron other than the loop of Henle and hypertension.<a class="elsevierStyleCrossRef" href="#bib0325">9</a> Evidence regarding the effect of low-dose aspirin (<1 mg/kg/day) on diuretic response in particular is more scarce and controversial. A previous study reported that chronic low-dose aspirin could profoundly affect platelet prostaglandin production without affecting diuretic-stimulated renal prostacyclin production or plasma renin activity.<a class="elsevierStyleCrossRef" href="#bib0415">27</a> However, more recently, Jhund et al. demonstrated that the venodilation that occurs following furosemide administration could be inhibited by both high and low dose-aspirin.<a class="elsevierStyleCrossRef" href="#bib0420">28</a> Furthermore, Hall noted an important reduction in the need for diuretics when daily aspirin administration was stopped.<a class="elsevierStyleCrossRef" href="#bib0425">29</a> There is also some evidence that aspirin, even at a low dose, may neutralize the favorable effects of angiotensin-converting enzyme inhibitors by blocking prostaglandin production and enhancing the vasoconstrictor potential of endothelin.<a class="elsevierStyleCrossRef" href="#bib0430">30</a> In patients with HF, aspirin should be avoided wherever possible and other antithrombotic agents that respect the integrity of prostaglandin metabolism should be considered.Treatment options for diuretic resistanceOverall, there is a lack of high-quality clinical data to guide the choice of treatment strategy to overcome diuretic resistance.<a class="elsevierStyleCrossRef" href="#bib0435">31</a> Several strategies can be employed to aid decongestion in patients with acute HF manifesting an impaired diuretic response. These include diuretic and nondiuretic strategies (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>).<a class="elsevierStyleCrossRef" href="#bib0385">21</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>Before considering the following treatment options, other causes of apparent diuretic resistance, such as third-space overload with intravascular volume depletion, must be ruled out.Salt restrictionDietary sodium restriction is a key determinant of diuretic efficacy. When dietary sodium intake is high, post-diuretic sodium retention compensates almost entirely for the loop-diuretic-induced sodium loss. Conversely, if sodium intake is restricted, post-diuretic sodium retention is minimized, resulting in a negative fluid and sodium balance.<a class="elsevierStyleCrossRef" href="#bib0440">32</a> Thus, restricting sodium intake to less than 100 mEq/day mitigates the effect of post-diuretic sodium retention and helps achieve a negative sodium balance. A 24-hour urinary sodium excretion of more than 100 mEq/day or a fractional excretion of sodium value >2% indicates non-compliance with sodium restriction and rules out true diuretic resistance.<a class="elsevierStyleCrossRef" href="#bib0355">15</a>Discontinue concomitant use of nonsteroidal anti-inflammatory drugsConcomitant use of NSAIDs is a major cause of diuretic failure and discontinuing them can significantly improve diuretic effectiveness.<a class="elsevierStyleCrossRef" href="#bib0355">15</a>Establish the effective single doseDiuretics have a dose-response curve and the effect only begins once the diuretic level reaches a therapeutic threshold within the renal tubular lumen. In conditions such as CKD and cardiorenal syndrome, the dose-response curve shifts downwards and towards the right. This means that these patients need higher doses of loop diuretics to achieve the therapeutic drug level at the site of action. Diuretic doses below said threshold are ineffective, so a higher effective single loop diuretic dose is needed rather than administering an inadequate dose more frequently.<a class="elsevierStyleCrossRef" href="#bib0355">15</a>Increase dose frequency of loop diureticsBecause most loop diuretics are short acting, increasing the dose frequency can help overcome post-diuretic sodium retention and restore diuretic response.<a class="elsevierStyleCrossRef" href="#bib0355">15</a>Diuretic substitutionGastrointestinal absorption and the bioavailability of different diuretics belonging to the same class can vary considerably and this could be a factor behind a poor response. Furosemide has a bioavailability of about 50%, whereas torsemide and bumetanide have almost complete absorption (80-100%). At times, replacing furosemide with comparable doses of bumetanide or torsemide can be enough to improve diuresis.<a class="elsevierStyleCrossRef" href="#bib0355">15</a>Intravenous diureticsSometimes, administering diuretics intravenously instead of orally is all that is needed to improve diuresis. Oral absorption may be altered in the presence of gastrointestinal edema, gastroparesis and delayed gastric emptying. Drug concentration at the site of diuretic action in the tubule lumen may be inadequate, due to decompensated HF, renal hypoperfusion or impaired secretion as a result of hypoalbuminemia.<a class="elsevierStyleCrossRef" href="#bib0440">32</a>Compared to bolus doses, continuous diuretic infusion may be more effective in improving diuresis. It may decrease fluctuations in intravascular volume, resulting in a more gradual and relatively constant hourly urine output and limiting the effect of post-diuretic sodium retention. Some studies found that furosemide administered as a continuous infusion was more effective than intermittent bolus doses, since significantly less furosemide was required to produce the same diuresis and due to the elimination of a diuretic-free interval (during which compensatory sodium retention occurs). Said studies found no significant differences in adverse effects and no change in serum creatinine or hospital mortality.<a class="elsevierStyleCrossRefs" href="#bib0445">33,34</a> Other studies reported that both regimens were equally effective in achieving a negative fluid balance.<a class="elsevierStyleCrossRef" href="#bib0440">32</a> In the Diuretic Optimization Strategies Evaluation (DOSE) trial, there were no significant differences in patients’ global symptom assessment or in the change in renal function between the two strategies.<a class="elsevierStyleCrossRef" href="#bib0290">2</a> Despite the conflicting evidence, pharmacodynamic concepts support the improved efficacy of continuous infusion of all loop diuretics except ethacrynic acid. A bolus dose of a loop diuretic should be administered before initiating a continuous infusion or when the infusion rate is increased in order to decrease the time for the drug's onset of action (<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>).<a class="elsevierStyleCrossRefs" href="#bib0440">32,35</a><elsevierMultimedia ident="tbl0020"></elsevierMultimedia>Sequential nephron blockadeA sequential sodium uptake blockade in different nephron segments by means of a combination of two or more diuretics from different classes may produce an additive or synergistic mechanism of action and diuretic response, and can be an effective approach in resistant cases (<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>).<a class="elsevierStyleCrossRef" href="#bib0355">15</a> For edematous disorders other than liver cirrhosis and ascites, the evidence for specific diuretic combinations is less clear.<a class="elsevierStyleCrossRef" href="#bib0460">36</a> The use of a loop diuretic and a thiazide or thiazide-like diuretic with or without a potassium-sparing agent is most common in practice.<a class="elsevierStyleCrossRef" href="#bib0355">15</a> Nevertheless, in the absence of evidence on the comparative efficacies of the various diuretic combinations, choosing a strategy should be based on patient-specific factors and the side effect profiles of the different combinations.<a class="elsevierStyleCrossRef" href="#bib0435">31</a><elsevierMultimedia ident="tbl0025"></elsevierMultimedia>Thiazide diuretics inhibit sodium reabsorption in the distal convoluted tubule and can thus counteract compensatory distal tubular hypertrophy.<a class="elsevierStyleCrossRef" href="#bib0435">31</a> Metolazone and hydrochlorothiazide are the two thiazides most commonly used in combination with furosemide, although there is no clear evidence that one is superior to the other, neither in terms of their efficacy in increasing diuresis nor their safety with regard to renal function and electrolyte abnormalities.<a class="elsevierStyleCrossRefs" href="#bib0440">32,37,38</a> When initiating combination therapy, thiazides should be administered before intravenous loop diuretics to allow enough time for the full blockade of the distal nephron.<a class="elsevierStyleCrossRef" href="#bib0440">32</a> Case studies and small observational trials reported effective diuresis in 75-90% of patients who received thiazide diuretics in addition to loop diuretic therapy.<a class="elsevierStyleCrossRef" href="#bib0435">31</a> However, one drawback of thiazide-type diuretics is that they limit the kidneys’ capacity to produce diluted urine and thus free water clearance and they should therefore be avoided in hypotonic hyponatremia.<a class="elsevierStyleCrossRef" href="#bib0345">13</a>There is a paucity of data regarding specific mineralocorticoid receptor antagonists use in acute HF and the combination of spironolactone and loop diuretics has not been shown to be synergistic. Nevertheless, said drugs exhibit mild but effective natriuretic effects and minimize potassium wasting by loop diuretics.<a class="elsevierStyleCrossRefs" href="#bib0320">8,13</a> Moreover, spironolactone or eplerenone are recommended in all symptomatic patients (despite treatment with an angiotensin-converting enzyme inhibitor and a beta-blocker) with HF and a reduced ejection fraction in order to reduce mortality and HF hospitalization.<a class="elsevierStyleCrossRef" href="#bib0435">31</a> Therefore, there may be a strong rationale to continue and even increase dosing of these drugs when the glomerular filtration rate is stable and serum potassium levels are less than 5.5 mEq/l.<a class="elsevierStyleCrossRefs" href="#bib0320">8,13</a>While the diuretic and natriuretic capacity of acetazolamide is poor on its own, it could well be a very efficient booster of diuretic efficacy. The combination of acetazolamide and a loop diuretic can be very effective, blocking more than 90% of sodium reabsorption in the nephron. Moreover, it reduces renin release with potentially favorable effects on neurohormonal activation. However, there are currently no data on the benefits of acetazolamide as add-on therapy and long-term use can cause metabolic acidosis.<a class="elsevierStyleCrossRefs" href="#bib0345">13,15</a>Combination therapy is associated with a significant increase in adverse effects such as electrolyte imbalances, dehydration and renal impairment. It requires careful monitoring and is best reserved for the occasional patient with high resistance to loop diuretics.<a class="elsevierStyleCrossRefs" href="#bib0355">15,32</a>Management of intra-abdominal pressureIntra-abdominal hypertension is defined as a sustained intra-abdominal pressure of 12 mmHg or above. Splanchnic and interstitial congestion may cause elevated intra-abdominal pressure in the absence of ascites in acute decompensated HF. In such patients, a rise in intra-abdominal pressure increases renal venous pressure, thereby reducing the transrenal perfusion gradient and renal perfusion. Elevated intra-abdominal pressure also causes increased renal interstitial pressure that opposes net filtration pressure. Both contribute to renal impairment and diuretic resistance. When intravenous loop diuretic therapy fails, measuring intra-abdominal pressure is an inexpensive and minimally invasive procedure that rules out a diuretic resistance cause. If intra-abdominal hypertension or abdominal compartment syndrome (defined as a sustained intra-abdominal pressure of >20 mmHg which is associated with new organ dysfunction) is identified, a reduction in intra-abdominal pressure by mobilizing third-space fluid can be achieved through a combination of diuretics, vasodilators and/or inotropes. Abundant ascites can be managed with paracentesis, ultrasound or computer tomography guidance if needed. In certain patients, ultrafiltration (UF) may be appropriate. The therapeutic aim is to achieve an abdominal perfusion pressure (calculated as the mean arterial pressure minus the intra-abdominal pressure) of over 60 mmHg (with an intra-abdominal pressure of 5 to 7 mmHg), which signifies a favorable outcome (improvement in renal perfusion, renal filtration and diuresis).<a class="elsevierStyleCrossRef" href="#bib0405">25</a>Infusion with albuminSimultaneous infusion of a diuretic and albumin could slightly improve diuretic resistance. A meta-analysis of eight randomized clinical trials of adults with hypoalbuminemia, comparing the co-administration of loop diuretics and albumin versus loop diuretics alone, found transient effects of modest clinical significance with the former strategy.<a class="elsevierStyleCrossRef" href="#bib0475">39</a> However, this intervention should only be considered in severely hypoalbuminemic patients when the approaches discussed above have failed.<a class="elsevierStyleCrossRef" href="#bib0355">15</a>Renal-dose dopamineLow doses of dopamine (<3 μg/kg/min) selectively work on peripheral dopaminergic receptors resulting in vasodilation in the renal, coronary, splanchnic and cerebral circulations. Two recent trials of dopamine in acute HF – the Dopamine in Acute Decompensated Heart Failure II (DAD-HF II) trial and the Renal Optimization Strategies Evaluation (ROSE) trial – have shown no added benefit with the addition of dopamine to standard therapy with high-dose diuretics. Thus, on the basis of current data, dopamine has no role in nonhypotensive patients with acute HF. In the absence of cardiogenic shock, however, the role of low-dose dopamine in acute HF with hypotension merits further study.<a class="elsevierStyleCrossRefs" href="#bib0385">21,31</a>Alternative pharmacological therapiesHypertonic saline works osmotically to pull free water from the interstitial fluid into the renal vasculature. In addition to increasing renal blood flow, it improves sodium delivery to the loop of Henle, thus restoring some of the loop diuretics’ effect. Several studies have reported better diuresis, improved renal function and shorter hospital stays when hypertonic saline is added to loop diuretic therapy.<a class="elsevierStyleCrossRef" href="#bib0435">31</a>Nesiritide is a synthetic B-type natriuretic peptide (BNP) approved by the Food and Drug Administration for symptomatic relief due to its favorable effects on hemodynamics, dyspnea and renal function. However, both the ROSE trial and ter Maaten et al. (2015) found no additive effect of using low-dose nesiritide added to diuretic therapy in terms of decongestion or improved renal function. Experimental research has shown that renal delivery of BNP had significantly greater beneficial effects than systemic delivery. It could be that a higher systemic dose is needed; however, the usage thereof would increase the incidence of adverse effects such as hypotension.<a class="elsevierStyleCrossRefs" href="#bib0370">18,40</a>Furthermore, it is worth noting that HF trials on nesiritide and dopamine have not been specific to patients exhibiting a resistance to loop diuretics.<a class="elsevierStyleCrossRef" href="#bib0435">31</a>Vasopressin-2-receptor antagonists may promote aquaresis by blocking the effects of vasopressin on the vasopressin 2 receptors located in the collecting ducts, thus blocking the re-absorption of free water. This promotes water clearance without affecting sodium balance. In the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial, tolvaptan at a dose of 30 mg once daily for a minimum of 60 days had no effect on total mortality or HF hospitalization when compared to placebo.<a class="elsevierStyleCrossRefs" href="#bib0385">21,41</a>Adenosine antagonists can potentially increase glomerular filtration and enhance the diuretic effect of diuretic drugs. However, the Placebo-Controlled Randomized Study of the Selective Adenosine A1 Receptor Antagonist Rolofylline for Patients Hospitalized with Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function (PROTECT) trial did not report any beneficial effects on congestion or renal function and was associated with an increased risk of seizures.<a class="elsevierStyleCrossRefs" href="#bib0385">21,42</a>Glucocorticoids may promote diuresis and protect renal function in patients with acute HF. Liu et al. reported the effects of prednisolone in 13 congestive HF patients with significant volume overload and diuretic resistance who had failed to respond to a conventional sequential nephron blockade treatment strategy. They reported an improvement in diuresis, clinical status and renal function.<a class="elsevierStyleCrossRef" href="#bib0495">43</a> The same author later reviewed the available evidence and concluded that the short-term use of glucocorticoids, when added to maximum conventional therapy, can potentiate renal responsiveness to diuretic therapy in patients with HF.<a class="elsevierStyleCrossRef" href="#bib0500">44</a> However, larger randomized double-blind placebo-controlled studies are warranted to demonstrate their safety and efficacy in such patients. The proposed mechanism of action of glucocorticoids includes increased expression of natriuretic peptide receptor-A in the kidney and the hypothalamus, which appear to be reduced in patients with HF, also increasing renal blood flow through dilatation of the renal vasculature via increased renal prostaglandin, nitric oxide and dopamine production.<a class="elsevierStyleCrossRefs" href="#bib0385">21,43,44</a>Levosimendan was studied in patients presenting with acute HF in the Randomized Multicenter Evaluation of Intravenous Levosimendan Efficacy (REVIVE) studies. These showed that levosimendan improved renal function and diuretic response in such patients. However, there was also an increased risk of arrhythmia and hypotension.<a class="elsevierStyleCrossRef" href="#bib0385">21</a>Ularitide, a human endogenous natriuretic peptide expressed in the kidney, which induces natriuresis and diuresis by binding to a specific natriuretic peptide receptor, was investigated in patients with acute HF in the Efficacy and Safety of Ularitide for the Treatment of Acute Decompensated Heart Failure (TRUE-AHF) trial. Packer et al. reported favorable physiological effects (greater reductions in systolic blood pressure and in levels of N-terminal pro–BNP [NT-proBNP] than the placebo group, without affecting cardiac troponin levels). However, short-term treatment neither affected the initial 48-hour clinical course nor reduced long-term cardiovascular mortality.<a class="elsevierStyleCrossRefs" href="#bib0385">21,45</a>In the Efficacy and Safety of Relaxin for the Treatment of Acute Heart Failure (RELAX-AHF) trial, serelaxin, a human recombinant form of the vasodilator relaxin, showed no significant effect on diuretic response, but did have beneficial effects in preventing organ damage in patients with acute HF who were diuretic-resistant.<a class="elsevierStyleCrossRefs" href="#bib0385">21,46</a> The Efficacy, Safety and Tolerability of Serelaxin When Added to Standard Therapy in AHF (RELAX-AHF-2) trial was designed to confirm serelaxin's effect on these clinical outcomes but it did not meet either of its primary endpoints. There was no difference in cardiovascular mortality at 180 days and the trend for reducing worsening HF through day five with serelaxin was not statistically significant.<a class="elsevierStyleCrossRef" href="#bib0515">47</a>There are several other agents under investigation, which could play a role in aiding decongestion of patients presenting with acute HF, such as omecamtiv mecarbil and TRV027.<a class="elsevierStyleCrossRef" href="#bib0385">21</a>Omecamtiv mecarbil is a selective cardiac myosin activator that increases myocardial function in healthy volunteers and in patients with chronic HF. Its effects on patients with acute HF were evaluated in the Acute Treatment with Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure (ATOMIC-HF) trial. This study showed that omecamtiv mecarbil may improve dyspnea scores when higher doses were used in comparison to placebo; however, it did not significantly improve overall dyspnea scores – the primary endpoint of the study.<a class="elsevierStyleCrossRef" href="#bib0520">48</a>TRV027 is a novel ligand of the angiotensin II type 1 receptor, selectively antagonizing the negative effects of angiotensin II, while preserving the potential pro-contractility effects of angiotensin II type 1 receptor stimulation. Its safety and efficacy were assessed in the Biased ligand of the angiotensin II type 1 receptor in patients with acute heart failure (BLAST-AHF) trial and, although well tolerated, TRV027 did not improve clinical status through 30-day follow-up compared to placebo.<a class="elsevierStyleCrossRef" href="#bib0525">49</a>Further studies are needed to evaluate the safety and efficacy of these drug candidates in a larger group of patients with acute HF.UltrafiltrationUF is very effective at removing plasma fluid from blood across a semipermeable membrane that allows small molecules to pass through along its pressure gradient to the ultrafiltrate fluid.<a class="elsevierStyleCrossRef" href="#bib0385">21</a>Small studies suggest that UF improves pulmonary and peripheral edema, lung function and hemodynamics without adverse effects on renal function. The fluid removal rate is reevaluated using clinical assessment and serial hematocrit measurements to ensure appropriate vascular compartment refill.<a class="elsevierStyleCrossRef" href="#bib0385">21</a>The recent development of veno-venous peripheral UF has positioned this technique as a potential alternative to loop diuretics in acute HF.<a class="elsevierStyleCrossRef" href="#bib0385">21</a>The Relief for Acutely Fluid-Overloaded Patients With Decompensated Congestive Heart Failure (RAPID-CHF) trial, a multicenter randomized controlled trial involving forty patients, found that UF was feasible, well-tolerated, and resulted in significant weight loss and fluid removal.<a class="elsevierStyleCrossRef" href="#bib0530">50</a>Favorable outcomes were also reported in the Ultrafiltration versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Congestive Heart Failure (UNLOAD) trial. This prospective, randomized, multicenter trial involving 200 patients, found that UF safely produces greater weight and fluid loss than intravenous diuretics, reduces 90-day resource utilization for HF and is an effective alternative therapy.<a class="elsevierStyleCrossRef" href="#bib0535">51</a>In the Ultrafiltration vs. Diuretics in Decompensated HF (ULTRADISCO) study, a prospective, randomized, open-label, single-center study which included 30 patients, the use of UF was associated with greater hemodynamic stability and with a greater reduction in plasma levels of NT-proBNP and aldosterone compared to diuretic infusion.<a class="elsevierStyleCrossRef" href="#bib0540">52</a>In the Continuous Ultrafiltration for Congestive Heart Failure (CUORE) trial, UF as a first-line treatment in patients with severe congestive HF was associated with prolonged clinical stabilization and greater freedom from rehospitalization for congestive HF compared to standard medical therapy alone.<a class="elsevierStyleCrossRef" href="#bib0545">53</a>The Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARRESS-HF), however, found a stepped pharmacologic-therapy algorithm to be superior to UF for the preservation of renal function at 96 hours, with a similar amount of weight loss seen with the two approaches and a higher rate of adverse events observed with UF.<a class="elsevierStyleCrossRef" href="#bib0550">54</a>Results of the Reverse Worsening Renal Function in Decompensated Heart Failure (REWORD-HF) study (which ended in April 2017) are still pending and will help determine whether fluid removal by UF is superior to different pharmacological approaches in acutely relieving congestion and preventing further deterioration in renal function and whether it results in longer admission-free survival 90 days after enrolment in patients with decompensated HF and cardiorenal syndrome.Seven randomized controlled trials, including several of those mentioned above, were submitted for a meta-analysis. UF was found to be an effective and safe therapeutic strategy, resulting in greater weight loss and fluid removal without affecting renal function, mortality or rehospitalization.<a class="elsevierStyleCrossRef" href="#bib0555">55</a>The 2016 European Society of Cardiology guidelines state that there is no evidence favoring UF over loop diuretics as first-line therapy in patients with acute HF. The former should thus be confined to patients who fail to respond to diuretic-based strategies.ConclusionDiuretic resistance has emerged as an independent factor behind worse HF patient outcomes, namely in-hospital worsening, early post-discharge mortality and rehospitalizations. While several mechanisms help to explain their reduced response to diuretics, the definition of the problem itself remains elusive. More recent evidence is leaning towards the coupling of parameters such as weight loss and urine output to diuretic dose, but several challenges remain. Non-pharmacological measures and a few medical options, such as continuous infusion of diuretics and sequential nephron blockade, may be used to overcome diuretic resistance. Nevertheless, disease progression may warrant more invasive methods for fluid removal. Therapy must be tailored on a case-by-case basis.Conflicts of interestThe authors have no conflicts of interest to declare." "textoCompletoSecciones" => array:1 [ "secciones" => array:12 [ 0 => array:3 [ "identificador" => "xres1127645" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1061248" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1127646" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1061249" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Diuretic resistance – defining the problem" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Pharmacokinetics & pharmacodynamics of loop diuretics" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Pathophysiology of diuretic resistance" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Reduced delivery of the diuretic to its site of action" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Neurohormonal activation" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Tubular compensatory readaptation" ] 3 => array:2 [ "identificador" => "sec0040" "titulo" => "Drug interactions" ] ] ] 8 => array:3 [ "identificador" => "sec0045" "titulo" => "Treatment options for diuretic resistance" "secciones" => array:12 [ 0 => array:2 [ "identificador" => "sec0050" "titulo" => "Salt restriction" ] 1 => array:2 [ "identificador" => "sec0055" "titulo" => "Discontinue concomitant use of nonsteroidal anti-inflammatory drugs" ] 2 => array:2 [ "identificador" => "sec0060" "titulo" => "Establish the effective single dose" ] 3 => array:2 [ "identificador" => "sec0065" "titulo" => "Increase dose frequency of loop diuretics" ] 4 => array:2 [ "identificador" => "sec0070" "titulo" => "Diuretic substitution" ] 5 => array:2 [ "identificador" => "sec0075" "titulo" => "Intravenous diuretics" ] 6 => array:2 [ "identificador" => "sec0080" "titulo" => "Sequential nephron blockade" ] 7 => array:2 [ "identificador" => "sec0085" "titulo" => "Management of intra-abdominal pressure" ] 8 => array:2 [ "identificador" => "sec0090" "titulo" => "Infusion with albumin" ] 9 => array:2 [ "identificador" => "sec0095" "titulo" => "Renal-dose dopamine" ] 10 => array:2 [ "identificador" => "sec0100" "titulo" => "Alternative pharmacological therapies" ] 11 => array:2 [ "identificador" => "sec0105" "titulo" => "Ultrafiltration" ] ] ] 9 => array:2 [ "identificador" => "sec0110" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0115" "titulo" => "Conflicts of interest" ] 11 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1061248" "palabras" => array:5 [ 0 => "Heart failure" 1 => "Diuretic resistance" 2 => "Loop diuretic" 3 => "Sequential nephron blockade" 4 => "Ultrafiltration" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec1061249" "palabras" => array:5 [ 0 => "Insuficiência cardíaca" 1 => "Resistência aos diuréticos" 2 => "Diuréticos de ansa" 3 => "Bloqueio sequencial do nefrónio" 4 => "Ultrafiltração" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "Heart failure is a disease with high direct and indirect costs. Current treatment includes drugs that alter disease progression and drugs that to improve symptoms. Loop diuretics are the cornerstone of congestion relief for acute management, as well as for chronic stabilization. In heart failure patients, maximal diuretic response is reduced by many individual factors. Diuretic resistance is defined as failure to achieve effective congestion relief despite appropriate or escalating diuretic doses. Its causes include impaired delivery of the diuretic to its luminal site of action, neurohormonal activation, tubular compensatory adaptation and drug interactions. Several strategies can be employed to aid decongestion of patients with impaired diuretic response. These include salt restriction, a higher effective single dose or higher dose frequency of loop diuretics, continuous infusion of diuretics and/or sequential nephron blockade through a synergistic combination of two or more diuretics from different classes. Ultrafiltration has also been found to be another effective and safe therapeutic option and should be considered in patients with refractory diuretic resistance. Overall, there is a lack of high-quality clinical data to guide the choice of treatment strategy and therapy should be tailored on a case-by-case basis." ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "A insuficiência cardíaca é uma doença com custos diretos e indiretos elevados. A terapêutica atual inclui fármacos que alteram a progressão da doença e fármacos que melhoram a sintomatologia. Os diuréticos de ansa constituem a pedra basilar no alívio da congestão quer na abordagem aguda quer na estabilização crónica. Nos doentes com insuficiência cardíaca, a resposta diurética máxima encontra-se diminuída devido a múltiplos fatores. A resistência aos diuréticos é definida como a ausência de alívio eficaz da congestão apesar de doses apropriadas ou crescentes de diuréticos. As causas de resistência aos diuréticos incluem o compromisso da entrega de diurético no seu local de ação, a ativação neuro-hormonal, a adaptação compensatória tubular e interações medicamentosas. Podem ser implementadas várias estratégias para diminuir a congestão em doentes com resposta diurética insuficiente. Essas estratégias incluem restrição salina, aumento da dose ou frequência dos diuréticos de ansa, infusão contínua de diuréticos e/ou bloqueio sequencial do nefrónio através da combinação de dois ou mais diuréticos de diferentes classes e com efeitos sinérgicos. A ultrafiltração tem-se revelado uma outra estratégia segura e eficaz e deve ser considerada em doentes com resistência aos diuréticos refratária. Verifica-se globalmente uma escassez de dados clínicos de elevada qualidade para guiar a escolha da estratégia terapêutica pelo que a abordagem deve ser adequada caso a caso." ] ] "nomenclatura" => array:1 [ 0 => array:3 [ "identificador" => "nom0005" "titulo" => "Abbreviations" "listaDefinicion" => array:1 [ 0 => array:1 [ "definicion" => array:25 [ 0 => array:2 [ "termino" => "ATOMIC-HF" "descripcion" => "Acute Treatment with Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure" ] 1 => array:2 [ "termino" => "BNP" "descripcion" => "B-type natriuretic peptide" ] 2 => array:2 [ "termino" => "BLAST-AHF" "descripcion" => "Biased ligand of the angiotensin II type 1 receptor in patients with acute heart failure" ] 3 => array:2 [ "termino" => "CARRESS-HF" "descripcion" => "Cardiorenal Rescue Study in Acute Decompensated Heart Failure" ] 4 => array:2 [ "termino" => "CKD" "descripcion" => "Chronic kidney disease" ] 5 => array:2 [ "termino" => "CUORE" "descripcion" => "Continuous Ultrafiltration for Congestive Heart Failure" ] 6 => array:2 [ "termino" => "DOSE" "descripcion" => "Diuretic Optimization Strategies Evaluation" ] 7 => array:2 [ "termino" => "DAD-HF II" "descripcion" => "Dopamine in Acute Decompensated Heart Failure II" ] 8 => array:2 [ "termino" => "RELAX-AHF-2" "descripcion" => "Efficacy, Safety and Tolerability of Serelaxin When Added to Standard Therapy in Acute Heart Failure" ] 9 => array:2 [ "termino" => "RELAX-AHF" "descripcion" => "Efficacy and Safety of Relaxin for the Treatment of Acute Heart Failure" ] 10 => array:2 [ "termino" => "TRUE-AHF" "descripcion" => "Efficacy and Safety of Ularitide for the Treatment of Acute Decompensated Heart Failure" ] 11 => array:2 [ "termino" => "EVEREST" "descripcion" => "Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan" ] 12 => array:2 [ "termino" => "EPICA" "descripcion" => "Epidemiologia da Insuficiência Cardiaca e Aprendizagem" ] 13 => array:2 [ "termino" => "HF" "descripcion" => "Heart failure" ] 14 => array:2 [ "termino" => "NT-proBNP" "descripcion" => "N-terminal pro–BNP" ] 15 => array:2 [ "termino" => "NSAID" "descripcion" => "Nonsteroidal anti-inflammatory drug" ] 16 => array:2 [ "termino" => "PROTECT" "descripcion" => "Placebo-Controlled Randomized Study of the Selective Adenosine A1 Receptor Antagonist Rolofylline for Patients Hospitalized with Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function" ] 17 => array:2 [ "termino" => "REVIVE" "descripcion" => "Randomized Multicenter Evaluation of Intravenous Levosimendan Efficacy" ] 18 => array:2 [ "termino" => "RAPID-CHF" "descripcion" => "Relief for Acutely Fluid-Overloaded Patients With Decompensated Congestive Heart Failure" ] 19 => array:2 [ "termino" => "ROSE" "descripcion" => "Renal Optimization Strategies Evaluation" ] 20 => array:2 [ "termino" => "RAA" "descripcion" => "Renin-angiotensin-aldosterone" ] 21 => array:2 [ "termino" => "REWORD-HF" "descripcion" => "Reverse Worsening Renal Function in Decompensated Heart Failure" ] 22 => array:2 [ "termino" => "UF" "descripcion" => "Ultrafiltration" ] 23 => array:2 [ "termino" => "UNLOAD" "descripcion" => "Ultrafiltration versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Congestive Heart Failure" ] 24 => array:2 [ "termino" => "ULTRADISCO" "descripcion" => "Ultrafiltration vs. Diuretics in Decompensated Heart Failure" ] ] ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1943 "Ancho" => 2583 "Tamanyo" => 340799 ] ] "descripcion" => array:1 [ "en" => "Pathophysiology-based approach to diuretic resistance." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Adapted from Verbrugge FH, Mullens W & Tang WH (2016).<a class="elsevierStyleCrossRef" href="#bib0345">13</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author (year) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Metric \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Findings in patients with low diuretic efficacy \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Testani et al. (2014)<a class="elsevierStyleCrossRef" href="#bib0335">11</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Net fluid loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Higher all-cause mortality after 5 years (Penn Cohort)/180 days (Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness Cohort) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Valente et al. (2014)<a class="elsevierStyleCrossRef" href="#bib0305">5</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Weight loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Higher heart failure readmissions after 60 days Higher death, heart failure or renal-related readmissions after 60 days Higher all-cause mortality after 180 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Voors et al. (2014)<a class="elsevierStyleCrossRef" href="#bib0390">22</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Weight loss \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Higher death, heart failure or renal-related readmissions after 60 days Neutral effect on all-cause mortality after 180 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Singh et al. (2014)<a class="elsevierStyleCrossRef" href="#bib0340">12</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urinary sodium Furosemide concentration \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Higher death, transplantation or heart failure readmission after 5 months \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ter Maaten et al. (2015)<a class="elsevierStyleCrossRef" href="#bib0370">18</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Weight loss Urine output \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Higher death or heart failure readmission after 30 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Verbrugge et al. (2015)<a class="elsevierStyleCrossRef" href="#bib0330">10</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Natriuresis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Higher death or heart failure readmission after 188 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kumar et al. (2015)<a class="elsevierStyleCrossRef" href="#bib0375">19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Fractional sodium excretion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Higher all-cause mortality after 30 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ter Maaten et al. (2016)<a class="elsevierStyleCrossRef" href="#bib0380">20</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Chloride levels \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Higher mortality through 180 days \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aronson et al. (2016)<a class="elsevierStyleCrossRef" href="#bib0560">56</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Net fluid loss Urine output \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Higher all-cause mortality after 6 months \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1922120.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Relationship between diuretic efficacy and clinical outcomes in heart failure." ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Adapted from Hoorn EJ & Ellison DH (2017).<a class="elsevierStyleCrossRef" href="#bib0460">36</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Incorrect diagnosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Venous edema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Lymphatic edema \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Third space overload with intravascular volume depletion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nonadherence to recommended sodium and/or fluid restriction \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Poor diuretic delivery to the nephron lumen \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nonadherence \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dose too low or too infrequent \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Poor absorption (example: edematous gut) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypoalbuminemia and nephrotic syndrome \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hepatic cirrhosis \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Reduced diuretic secretion \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Tubular uptake of diuretic impaired by uremic toxins \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Decreased kidney blood flow \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Decreased functional kidney mass \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Insufficient kidney response to drug \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Low glomerular filtration rate \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Decreased effective intravascular volume despite elevated total extracellular fluid volume \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Activation of the renin-angiotensin-aldosterone axis and renal sympathetic nerves \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Increased sodium delivery and absorption in distal tubular segments \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Compensatory retention of sodium after the effective period of the diuretic \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nephron adaptation (hypertrophy and hyperplasia of distal tubular cells) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use of nonsteroidal anti-inflammatory drugs \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1922121.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Causes of diuretic resistance." ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Adapted from Bowman, Nawarskas & Anderson (2016).<a class="elsevierStyleCrossRef" href="#bib0435">31</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Strategy \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Summary of evidence \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Initial measures</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Intravenous diuretics \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Improved pharmacokinetics in compensated heart failure \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Initial measure in hospitalized patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Increase diuretic dose \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Doses of ≥500 mg/day of oral furosemide were safe High intravenous doses were safe and were more effective \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consider in mildly symptomatic ambulatory patients \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Use alternative loop diuretic (bumetanide and torsemide) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Greater enteral absorption and less affected by edematous states \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consider in case of poor response to oral furosemide  \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Continuous infusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Lower total daily doses to elicit the same degree of natriuresis compared to bolus doses without better symptom relief or creatinine improvements \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consider in case of inadequate response to bolus doses \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Combination of intravenous loop diuretics with one or more diuretics from different classes \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Thiazide/Metolazone – Increased urine sodium and/or weight loss - Acetazolamide – increased diuresis  \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consider in case of inadequate response to increasing doses of IV loop diuretics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">- Mineralocorticoid receptor antagonist – increased diuresis and faster symptom relief \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consider in ambulatory or outpatients with an inadequate response to loop diuretics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top"></td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="3" align="left" valign="top">Advanced measures</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hypertonic saline infusion \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Improved diuresis and renal function, and shortened hospitalizations \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consider when the above options have failed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Dopamine \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Similar urine output when added to low-dose intravenous furosemide compared with high-dose intravenous furosemide alone Subsequent trials have failed to demonstrate a benefit \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Consider only when all other options have failed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Nesiritide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">No improvement in urine output, hospital readmission or mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Should not be used in loop diuretic resistance \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1922122.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Strategies for treating diuretic resistance." ] ] 4 => array:8 [ "identificador" => "tbl0020" "etiqueta" => "Table 4" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at4" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Adapted from Brater (2011).<a class="elsevierStyleCrossRef" href="#bib0455">35</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Creatinine clearance (ml/min) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col">Loading dose (mg) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Infusion rate (mg/h)</th></tr><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">All levels \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><25 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">25-75 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">>75 \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Furosemide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">20 then 40 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 then 20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bumetanide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">1 then 2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">0.5 then 1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Torsemide \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">10 then 20 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">5 then 10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1922124.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Dosage regimens for continuous intravenous diuretic administration." ] ] 5 => array:8 [ "identificador" => "tbl0025" "etiqueta" => "Table 5" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at5" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "Adapted from Ellison (2001).<a class="elsevierStyleCrossRef" href="#bib0320">8</a>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">To an effective or maximal safe dose of a loop diuretic add: \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Distal convoluted tubule diuretics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Metolazone 2.5-10 mg per os daily (duration or frequency adjusted based on the target weight) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hydrochlorothiazide (or equivalent) 25-100 mg per os daily \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Chlorothiazide 500-1000 mg intravenously \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Proximal tubule diuretics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Acetazolamide 250-375 mg daily or up to 500 mg intravenously \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Potassium-sparing diuretics \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Spironolactone 100-200 mg daily \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Amiloride 5-10 mg daily \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1922123.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Combination diuretic therapy." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:56 [ 0 => array:3 [ "identificador" => "bib0285" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Diuretic resistance in heart failure" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "S. 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Review Article

A 2018 overview of diuretic resistance in heart failure

A resistência aos diuréticos na insuficiência cardíaca revisitada em 2018

Sofia Isabel Jardima,

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sofiaisabeljardim@gmail.com

Corresponding author.

, Luís Ramos dos Santosb, Inês Araújoc,d, Filipa Marquesc,d, Patrícia Brancoe, Augusta Gaspare, Cândida Fonsecac,d

a Unidade Funcional Medicina 1.2, Hospital de São José, Centro Hospitalar de Lisboa Central, Lisbon, Portugal

b Serviço de Medicina Interna, Hospital Central do Funchal, Funchal, Portugal

c Unidade de Insuficiência Cardíaca, Serviço de Medicina III, Hospital São Francisco Xavier, Lisbon, Portugal

d NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal

e Serviço de Nefrologia, Hospital de Santa Cruz, Centro Hospitalar de Lisboa Ocidental, Lisbon, Portugal

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        "titulo" => "A resist&#234;ncia aos diur&#233;ticos na insufici&#234;ncia card&#237;aca revisitada em 2018"
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pathophysiology-based approach to diuretic resistance&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Introduction</span><p id="par0130" class="elsevierStylePara elsevierViewall">The incidence of heart failure &#40;HF&#41; is 1&#37; among American patients over 65 years of age&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">1&#44;2</span></a> Portuguese figures from the 2002 <span class="elsevierStyleItalic">Epidemiologia da Insufici&#234;ncia Cardiaca e Aprendizagem</span> &#40;EPICA&#41; study concluded that the overall prevalence of HF is 4&#46;4&#37;&#44; peaking at 16&#37; in those over 80 years of age&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">3</span></a> It continues to be the primary discharge diagnosis among elderly American patients&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">4</span></a> Hospitalization for HF constitutes an ominous sign&#44; with half of patients readmitted in the subsequent six months and a mortality rate of 25-35&#37; at the end of the first year&#46;<a class="elsevierStyleCrossRefs" href="#bib0300"><span class="elsevierStyleSup">4&#44;5</span></a> Consequently&#44; HF is a high burden disease with elevated direct and indirect costs&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">1</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Current treatment includes drugs that alter disease progression such as angiotensin converting enzyme inhibitors&#44; angiotensin II receptor blockers or&#44; more recently&#44; sacubitril&#47;valsartan&#44; beta-blockers and mineralocorticoid receptor antagonists &#8211; in HF with reduced ejection fraction &#8211; and drugs used to improve symptoms such as diuretics&#44; namely loop diuretics&#46;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">6&#8211;8</span></a> Loop diuretics are the cornerstone of congestion relief and are widely used for acute management &#40;up to 90&#37; of patients&#41; as well as for chronic stabilization&#46;<a class="elsevierStyleCrossRefs" href="#bib0290"><span class="elsevierStyleSup">2&#44;5&#44;8&#8211;10</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Despite the fact that diuretics themselves are not linked to increased survival&#44;<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">6&#44;8</span></a> diuretic efficacy has been shown to prolong event-free survival&#44; regardless of glomerular filtration rate&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">5&#44;11&#8211;13</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">In this review&#44; we discuss the underlying pathophysiology of diuretic resistance in HF patients&#44; while providing several currently available evidence-based pharmacological and non-pharmacological strategies to overcome this problem &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The aim of this article is to summarize the existing data and highlight recent research on the subject&#44; providing an up-to-date and practical approach to diuretic resistance&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Diuretic resistance &#8211; defining the problem</span><p id="par0150" class="elsevierStylePara elsevierViewall">There is ample variation in the definition of diuretic-resistant patients&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">13</span></a> The general definition refers to the failure to achieve effective congestion relief despite appropriate or escalating doses of diuretics&#46;<a class="elsevierStyleCrossRefs" href="#bib0350"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Some early reports estimated the prevalence of diuretic resistance to be 20-30&#37; among HF patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0360"><span class="elsevierStyleSup">16&#44;17</span></a> However&#44; the lack of a formal definition makes it impossible to properly assess the numbers&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">9&#44;13&#44;15</span></a></p><p id="par0160" class="elsevierStylePara elsevierViewall">Recent data link furosemide-equivalent doses of loop diuretics &#40;for intravenous diuretics&#44; 1 mg of bumetanide&#44; 20 mg of torsemide and 40 mg of furosemide<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">11</span></a>&#41; to changes in several parameters such as weight loss&#44; urine output or natriuresis as means to diagnose diuretic resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">13</span></a> These studies are summarized in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0165" class="elsevierStylePara elsevierViewall">Depending on the study&#44; poor diuretic response may be defined as&#58; a weight change of 0 to 2&#46;7 kg per 40 mg of furosemide &#40;or equivalent&#41;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">18</span></a>&#59; a urinary diuretic response &#60;1400 ml per 40 mg of furosemide &#40;or equivalent&#41;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">18</span></a>&#59; a fractional excretion of sodium at baseline &#60;0&#46;2&#37;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">19</span></a>&#59; a urinary sodium concentration and urinary furosemide concentration ratio &#40;both obtained from spot urine samples&#41; &#60;2 mmol&#47;mg<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">12</span></a>&#59; and&#47;or lower chloride levels at baseline &#40;97 to 103 mEq&#47;l&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">20</span></a> However&#44; the correlation between different metrics remains poor and there is no cut-off to establish actual diuretic resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">13</span></a> Prospective trials are needed to properly validate these metrics&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Predictors of diuretic resistance&#44; on the other hand&#44; are more firmly established between studies and include&#58; low systemic blood pressure&#44; elevated blood urea nitrogen&#44; HF of ischemic origin and diabetes&#46;<a class="elsevierStyleCrossRefs" href="#bib0305"><span class="elsevierStyleSup">5&#44;11&#44;18&#44;22</span></a> These studies also found that diuretic resistance is an independent predictor of worse in-hospital outcomes for HF&#44; early post-discharge mortality and increased HF rehospitalization&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pharmacokinetics &#38; pharmacodynamics of loop diuretics</span><p id="par0175" class="elsevierStylePara elsevierViewall">The relationship between loop diuretic concentration and natriuresis can be illustrated through an S-shaped dose-response curve&#44;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">14</span></a> which means that a minimal concentration must be reached at the site of action before any response is noted&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">8</span></a> A normal dose-response relationship can be distorted by a variety of clinical conditions&#46; In HF patients&#44; the curve is shifted downwards and to the right&#44; which translates into a decreased maximal diuretic response&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">8</span></a> Furthermore&#44; during hospitalization&#44; diuretic response is affected by many individual factors<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">14</span></a> including&#44; but not limited to&#44; renal failure&#44; which also shifts the curve to the right&#44; meaning a higher dose of diuretics is needed to achieve the same degree of natriuresis&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">8</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Pathophysiology of diuretic resistance</span><p id="par0180" class="elsevierStylePara elsevierViewall">The pathophysiology of diuretic resistance is complex and several causes may be involved &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a> It stems from multiple factors&#44; including reduced delivery of the diuretic to its luminal site of action&#44; neurohormonal activation&#44; tubular compensatory adaptation and drug interactions&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Reduced delivery of the diuretic to its site of action</span><p id="par0185" class="elsevierStylePara elsevierViewall">Reduced delivery of the diuretic to its site of action is closely related to its decreased bioavailability&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">In HF patients&#44; increased peripheral and bowel wall edema leads to reduced absorption of the diuretic&#44; with a more marked effect when oral furosemide is used&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a></p><p id="par0195" class="elsevierStylePara elsevierViewall">HF itself as well as concurrent chronic kidney disease &#40;CKD&#41; &#40;urate and other competing organic acids&#41; may lead to decreased glomerular filtration rate&#44; which in turns leads to impaired secretion of diuretics &#40;namely furosemide&#41; by the organic acid transporter into the proximal tubule&#46; Reduced glomerular filtration rate can&#44; therefore&#44; reduce delivery or reduce active secretion of loop diuretics into their site of action&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">23</span></a> Moreover&#44; CKD has been proposed as a contributing factor to the development of HF overall&#44; regardless of left ventricular ejection fraction&#46; CKD leads to volume retention&#44; altered calcium&#8211;phosphate metabolism&#44; hyperparathyroidism&#44; vitamin D deficiency&#44; anemia&#44; and the accumulation of uremic toxins&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">24</span></a> Renal dysfunction caused by intra-abdominal hypertension and cardiorenal syndrome are also plausible mechanisms of diuretic resistance through venous congestion&#46;<a class="elsevierStyleCrossRefs" href="#bib0325"><span class="elsevierStyleSup">9&#44;25</span></a> Intra-abdominal hypertension relief improves renal perfusion&#44; renal filtration and diuresis&#46; It is usually present in up to 60&#37; of acutely decompensated HF patients&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">25</span></a> It is very important to emphasize the need to detect third-space overload as opposed to intravascular overload because both the kidneys and diuretic therapy can only act in vascular overload&#46; Persistent diuretic use in patients who are already suffering from intravascular volume depletion further activates the renin-angiotensin-aldosterone &#40;RAA&#41; axis and makes diuretic resistance dependent on renal blood flow&#46; Urinary sodium and chloride measurements may indicate when vascular volume has been optimized because they decrease as euvolemia approaches&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">13</span></a> These may serve as more reliable markers of decongestion as opposed to the clinical signs and symptoms traditionally used to guide decongestive therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">26</span></a> Clinical signs and symptoms lack sensitivity and specificity but do raise the need for further clinical evaluation&#46; Natriuretic peptides are helpful for diagnosis and prognosis but lack the power to properly monitor volume status&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">26</span></a> Newer approaches point to quantitative blood volume analysis as means to differentiate hypervolemia profiles&#46; Appropriate profiling of volume overload in HF&#44; according to blood volume&#44; has therapeutic implications and may aid patients with diuretic resistance&#44; redirecting them to other forms of decongestion&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">26</span></a></p><p id="par0200" class="elsevierStylePara elsevierViewall">Another mechanism of diuretic activity impairment involves increased re-absorption of sodium and chloride in the proximal tubule&#44; leading to decreased delivery of these substrates to the distal areas of the nephron where loop diuretics act&#46; This mechanism causes diuretic resistance through decreased substrate availability to the sodium-potassium-chloride cotransport system&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">13</span></a></p><p id="par0205" class="elsevierStylePara elsevierViewall">Albumin levels also correlate to diuretic action because they are high affinity albumin-binding molecules &#40;&#62;90&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">9</span></a> Hypoalbuminemia increases the drug distribution volume and prevents suitable kidney delivery&#46; On the other hand&#44; high levels of albuminuria decrease loop diuretic delivery&#46; Increased urine albumin binds to diuretics&#44; preventing their ligation to the sodium-potassium-chloride receptors and thus impairing their action&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Neurohormonal activation</span><p id="par0210" class="elsevierStylePara elsevierViewall">Neurohormonal activation is strongly related to RAA axis upregulation&#46; Loop diuretics can activate the RAA axis through a variety of mechanisms&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a> They induce renin secretion through the direct blockade of the macula densa sodium-potassium-chloride cotransport system&#44; thus leading to increased renin and aldosterone in a volume-independent pathway&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">8</span></a> Furthermore&#44; diuretics induce renal prostacyclin production&#44; which increases renin secretion&#46; Finally&#44; diuretics induce volume contraction&#44; thus activating renin secretion through vascular stimulation&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">8</span></a> RAA axis activation eventually leads to increased sodium reabsorption&#44; prompting the onset of post-diuretic sodium retention and the braking phenomenon&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a> Post-diuretic sodium retention is one of the processes through which diuretic resistance may be established and it arises as soon as the concentration of diuretic in the tubular fluid drops below the therapeutic threshold&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a> A negative net sodium balance in the 24 hours between natriuresis and post-diuretic sodium retention may not be achieved in the event of dietary noncompliance&#44; rendering the diuretic effect insignificant&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a> The braking phenomenon&#44; on the other hand&#44; is defined as the decrease in diuresis volume after multiple same-dose administrations of diuretic&#46; This is linked to RAA axis activation and compensatory changes in the nephron&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Tubular compensatory readaptation</span><p id="par0215" class="elsevierStylePara elsevierViewall">Tubular readaptation is another mechanism that helps explain reduced diuretic response&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a> Owing to the abovementioned activation of the RAA axis&#44; as well as the braking phenomenon&#44; proximal tubular reabsorption arises&#44; leading to increased sodium uptake in this area of the nephron&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a> Simultaneously&#44; the chronic use of loop diuretics &#8211; which inhibit sodium uptake in the loop of Henle &#8211; leads to increased sodium delivery to the distal tubular system&#44; resulting in compensatory hyperplasia and hypertrophy&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">9</span></a> This means that the patient would retain more sodium and thus water than a diuretic-na&#239;ve patient&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">13&#44;21</span></a> This resistance mechanism can be overcome using a sequential nephron blockade with thiazide diuretics&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">9</span></a></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Drug interactions</span><p id="par0220" class="elsevierStylePara elsevierViewall">Some drugs&#44; such as nonsteroidal anti-inflammatory drugs &#40;NSAIDs&#41;&#44; can reduce the effect of diuretics&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a></p><p id="par0225" class="elsevierStylePara elsevierViewall">NSAIDs may cause diuretic resistance in a number of ways&#44; particularly&#58; decreased prostaglandin synthesis&#44; decreased renal vasodilation&#44; increased renal reabsorption in areas of the nephron other than the loop of Henle and hypertension&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">9</span></a> Evidence regarding the effect of low-dose aspirin &#40;&#60;1 mg&#47;kg&#47;day&#41; on diuretic response in particular is more scarce and controversial&#46; A previous study reported that chronic low-dose aspirin could profoundly affect platelet prostaglandin production without affecting diuretic-stimulated renal prostacyclin production or plasma renin activity&#46;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">27</span></a> However&#44; more recently&#44; Jhund et al&#46; demonstrated that the venodilation that occurs following furosemide administration could be inhibited by both high and low dose-aspirin&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">28</span></a> Furthermore&#44; Hall noted an important reduction in the need for diuretics when daily aspirin administration was stopped&#46;<a class="elsevierStyleCrossRef" href="#bib0425"><span class="elsevierStyleSup">29</span></a> There is also some evidence that aspirin&#44; even at a low dose&#44; may neutralize the favorable effects of angiotensin-converting enzyme inhibitors by blocking prostaglandin production and enhancing the vasoconstrictor potential of endothelin&#46;<a class="elsevierStyleCrossRef" href="#bib0430"><span class="elsevierStyleSup">30</span></a> In patients with HF&#44; aspirin should be avoided wherever possible and other antithrombotic agents that respect the integrity of prostaglandin metabolism should be considered&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Treatment options for diuretic resistance</span><p id="par0230" class="elsevierStylePara elsevierViewall">Overall&#44; there is a lack of high-quality clinical data to guide the choice of treatment strategy to overcome diuretic resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">31</span></a> Several strategies can be employed to aid decongestion in patients with acute HF manifesting an impaired diuretic response&#46; These include diuretic and nondiuretic strategies &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0235" class="elsevierStylePara elsevierViewall">Before considering the following treatment options&#44; other causes of apparent diuretic resistance&#44; such as third-space overload with intravascular volume depletion&#44; must be ruled out&#46;</p><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Salt restriction</span><p id="par0240" class="elsevierStylePara elsevierViewall">Dietary sodium restriction is a key determinant of diuretic efficacy&#46; When dietary sodium intake is high&#44; post-diuretic sodium retention compensates almost entirely for the loop-diuretic-induced sodium loss&#46; Conversely&#44; if sodium intake is restricted&#44; post-diuretic sodium retention is minimized&#44; resulting in a negative fluid and sodium balance&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">32</span></a> Thus&#44; restricting sodium intake to less than 100 mEq&#47;day mitigates the effect of post-diuretic sodium retention and helps achieve a negative sodium balance&#46; A 24-hour urinary sodium excretion of more than 100 mEq&#47;day or a fractional excretion of sodium value &#62;2&#37; indicates non-compliance with sodium restriction and rules out true diuretic resistance&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discontinue concomitant use of nonsteroidal anti-inflammatory drugs</span><p id="par0245" class="elsevierStylePara elsevierViewall">Concomitant use of NSAIDs is a major cause of diuretic failure and discontinuing them can significantly improve diuretic effectiveness&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Establish the effective single dose</span><p id="par0250" class="elsevierStylePara elsevierViewall">Diuretics have a dose-response curve and the effect only begins once the diuretic level reaches a therapeutic threshold within the renal tubular lumen&#46; In conditions such as CKD and cardiorenal syndrome&#44; the dose-response curve shifts downwards and towards the right&#46; This means that these patients need higher doses of loop diuretics to achieve the therapeutic drug level at the site of action&#46; Diuretic doses below said threshold are ineffective&#44; so a higher effective single loop diuretic dose is needed rather than administering an inadequate dose more frequently&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Increase dose frequency of loop diuretics</span><p id="par0255" class="elsevierStylePara elsevierViewall">Because most loop diuretics are short acting&#44; increasing the dose frequency can help overcome post-diuretic sodium retention and restore diuretic response&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Diuretic substitution</span><p id="par0260" class="elsevierStylePara elsevierViewall">Gastrointestinal absorption and the bioavailability of different diuretics belonging to the same class can vary considerably and this could be a factor behind a poor response&#46; Furosemide has a bioavailability of about 50&#37;&#44; whereas torsemide and bumetanide have almost complete absorption &#40;80-100&#37;&#41;&#46; At times&#44; replacing furosemide with comparable doses of bumetanide or torsemide can be enough to improve diuresis&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Intravenous diuretics</span><p id="par0265" class="elsevierStylePara elsevierViewall">Sometimes&#44; administering diuretics intravenously instead of orally is all that is needed to improve diuresis&#46; Oral absorption may be altered in the presence of gastrointestinal edema&#44; gastroparesis and delayed gastric emptying&#46; Drug concentration at the site of diuretic action in the tubule lumen may be inadequate&#44; due to decompensated HF&#44; renal hypoperfusion or impaired secretion as a result of hypoalbuminemia&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">32</span></a></p><p id="par0270" class="elsevierStylePara elsevierViewall">Compared to bolus doses&#44; continuous diuretic infusion may be more effective in improving diuresis&#46; It may decrease fluctuations in intravascular volume&#44; resulting in a more gradual and relatively constant hourly urine output and limiting the effect of post-diuretic sodium retention&#46; Some studies found that furosemide administered as a continuous infusion was more effective than intermittent bolus doses&#44; since significantly less furosemide was required to produce the same diuresis and due to the elimination of a diuretic-free interval &#40;during which compensatory sodium retention occurs&#41;&#46; Said studies found no significant differences in adverse effects and no change in serum creatinine or hospital mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0445"><span class="elsevierStyleSup">33&#44;34</span></a> Other studies reported that both regimens were equally effective in achieving a negative fluid balance&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">32</span></a> In the Diuretic Optimization Strategies Evaluation &#40;DOSE&#41; trial&#44; there were no significant differences in patients&#8217; global symptom assessment or in the change in renal function between the two strategies&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">2</span></a> Despite the conflicting evidence&#44; pharmacodynamic concepts support the improved efficacy of continuous infusion of all loop diuretics except ethacrynic acid&#46; A bolus dose of a loop diuretic should be administered before initiating a continuous infusion or when the infusion rate is increased in order to decrease the time for the drug&#39;s onset of action &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">32&#44;35</span></a></p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Sequential nephron blockade</span><p id="par0275" class="elsevierStylePara elsevierViewall">A sequential sodium uptake blockade in different nephron segments by means of a combination of two or more diuretics from different classes may produce an additive or synergistic mechanism of action and diuretic response&#44; and can be an effective approach in resistant cases &#40;<a class="elsevierStyleCrossRef" href="#tbl0025">Table 5</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a> For edematous disorders other than liver cirrhosis and ascites&#44; the evidence for specific diuretic combinations is less clear&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">36</span></a> The use of a loop diuretic and a thiazide or thiazide-like diuretic with or without a potassium-sparing agent is most common in practice&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a> Nevertheless&#44; in the absence of evidence on the comparative efficacies of the various diuretic combinations&#44; choosing a strategy should be based on patient-specific factors and the side effect profiles of the different combinations&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">31</span></a></p><elsevierMultimedia ident="tbl0025"></elsevierMultimedia><p id="par0280" class="elsevierStylePara elsevierViewall">Thiazide diuretics inhibit sodium reabsorption in the distal convoluted tubule and can thus counteract compensatory distal tubular hypertrophy&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">31</span></a> Metolazone and hydrochlorothiazide are the two thiazides most commonly used in combination with furosemide&#44; although there is no clear evidence that one is superior to the other&#44; neither in terms of their efficacy in increasing diuresis nor their safety with regard to renal function and electrolyte abnormalities&#46;<a class="elsevierStyleCrossRefs" href="#bib0440"><span class="elsevierStyleSup">32&#44;37&#44;38</span></a> When initiating combination therapy&#44; thiazides should be administered before intravenous loop diuretics to allow enough time for the full blockade of the distal nephron&#46;<a class="elsevierStyleCrossRef" href="#bib0440"><span class="elsevierStyleSup">32</span></a> Case studies and small observational trials reported effective diuresis in 75-90&#37; of patients who received thiazide diuretics in addition to loop diuretic therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">31</span></a> However&#44; one drawback of thiazide-type diuretics is that they limit the kidneys&#8217; capacity to produce diluted urine and thus free water clearance and they should therefore be avoided in hypotonic hyponatremia&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">13</span></a></p><p id="par0285" class="elsevierStylePara elsevierViewall">There is a paucity of data regarding specific mineralocorticoid receptor antagonists use in acute HF and the combination of spironolactone and loop diuretics has not been shown to be synergistic&#46; Nevertheless&#44; said drugs exhibit mild but effective natriuretic effects and minimize potassium wasting by loop diuretics&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">8&#44;13</span></a> Moreover&#44; spironolactone or eplerenone are recommended in all symptomatic patients &#40;despite treatment with an angiotensin-converting enzyme inhibitor and a beta-blocker&#41; with HF and a reduced ejection fraction in order to reduce mortality and HF hospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">31</span></a> Therefore&#44; there may be a strong rationale to continue and even increase dosing of these drugs when the glomerular filtration rate is stable and serum potassium levels are less than 5&#46;5 mEq&#47;l&#46;<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">8&#44;13</span></a></p><p id="par0290" class="elsevierStylePara elsevierViewall">While the diuretic and natriuretic capacity of acetazolamide is poor on its own&#44; it could well be a very efficient booster of diuretic efficacy&#46; The combination of acetazolamide and a loop diuretic can be very effective&#44; blocking more than 90&#37; of sodium reabsorption in the nephron&#46; Moreover&#44; it reduces renin release with potentially favorable effects on neurohormonal activation&#46; However&#44; there are currently no data on the benefits of acetazolamide as add-on therapy and long-term use can cause metabolic acidosis&#46;<a class="elsevierStyleCrossRefs" href="#bib0345"><span class="elsevierStyleSup">13&#44;15</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">Combination therapy is associated with a significant increase in adverse effects such as electrolyte imbalances&#44; dehydration and renal impairment&#46; It requires careful monitoring and is best reserved for the occasional patient with high resistance to loop diuretics&#46;<a class="elsevierStyleCrossRefs" href="#bib0355"><span class="elsevierStyleSup">15&#44;32</span></a></p></span><span id="sec0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Management of intra-abdominal pressure</span><p id="par0300" class="elsevierStylePara elsevierViewall">Intra-abdominal hypertension is defined as a sustained intra-abdominal pressure of 12 mmHg or above&#46; Splanchnic and interstitial congestion may cause elevated intra-abdominal pressure in the absence of ascites in acute decompensated HF&#46; In such patients&#44; a rise in intra-abdominal pressure increases renal venous pressure&#44; thereby reducing the transrenal perfusion gradient and renal perfusion&#46; Elevated intra-abdominal pressure also causes increased renal interstitial pressure that opposes net filtration pressure&#46; Both contribute to renal impairment and diuretic resistance&#46; When intravenous loop diuretic therapy fails&#44; measuring intra-abdominal pressure is an inexpensive and minimally invasive procedure that rules out a diuretic resistance cause&#46; If intra-abdominal hypertension or abdominal compartment syndrome &#40;defined as a sustained intra-abdominal pressure of &#62;20 mmHg which is associated with new organ dysfunction&#41; is identified&#44; a reduction in intra-abdominal pressure by mobilizing third-space fluid can be achieved through a combination of diuretics&#44; vasodilators and&#47;or inotropes&#46; Abundant ascites can be managed with paracentesis&#44; ultrasound or computer tomography guidance if needed&#46; In certain patients&#44; ultrafiltration &#40;UF&#41; may be appropriate&#46; The therapeutic aim is to achieve an abdominal perfusion pressure &#40;calculated as the mean arterial pressure minus the intra-abdominal pressure&#41; of over 60 mmHg &#40;with an intra-abdominal pressure of 5 to 7 mmHg&#41;&#44; which signifies a favorable outcome &#40;improvement in renal perfusion&#44; renal filtration and diuresis&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">25</span></a></p></span><span id="sec0090" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Infusion with albumin</span><p id="par0305" class="elsevierStylePara elsevierViewall">Simultaneous infusion of a diuretic and albumin could slightly improve diuretic resistance&#46; A meta-analysis of eight randomized clinical trials of adults with hypoalbuminemia&#44; comparing the co-administration of loop diuretics and albumin versus loop diuretics alone&#44; found transient effects of modest clinical significance with the former strategy&#46;<a class="elsevierStyleCrossRef" href="#bib0475"><span class="elsevierStyleSup">39</span></a> However&#44; this intervention should only be considered in severely hypoalbuminemic patients when the approaches discussed above have failed&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">15</span></a></p></span><span id="sec0095" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Renal-dose dopamine</span><p id="par0310" class="elsevierStylePara elsevierViewall">Low doses of dopamine &#40;&#60;3 &#956;g&#47;kg&#47;min&#41; selectively work on peripheral dopaminergic receptors resulting in vasodilation in the renal&#44; coronary&#44; splanchnic and cerebral circulations&#46; Two recent trials of dopamine in acute HF &#8211; the Dopamine in Acute Decompensated Heart Failure II &#40;DAD-HF II&#41; trial and the Renal Optimization Strategies Evaluation &#40;ROSE&#41; trial &#8211; have shown no added benefit with the addition of dopamine to standard therapy with high-dose diuretics&#46; Thus&#44; on the basis of current data&#44; dopamine has no role in nonhypotensive patients with acute HF&#46; In the absence of cardiogenic shock&#44; however&#44; the role of low-dose dopamine in acute HF with hypotension merits further study&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">21&#44;31</span></a></p></span><span id="sec0100" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Alternative pharmacological therapies</span><p id="par0315" class="elsevierStylePara elsevierViewall">Hypertonic saline works osmotically to pull free water from the interstitial fluid into the renal vasculature&#46; In addition to increasing renal blood flow&#44; it improves sodium delivery to the loop of Henle&#44; thus restoring some of the loop diuretics&#8217; effect&#46; Several studies have reported better diuresis&#44; improved renal function and shorter hospital stays when hypertonic saline is added to loop diuretic therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">31</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">Nesiritide is a synthetic B-type natriuretic peptide &#40;BNP&#41; approved by the Food and Drug Administration for symptomatic relief due to its favorable effects on hemodynamics&#44; dyspnea and renal function&#46; However&#44; both the ROSE trial and ter Maaten et al&#46; &#40;2015&#41; found no additive effect of using low-dose nesiritide added to diuretic therapy in terms of decongestion or improved renal function&#46; Experimental research has shown that renal delivery of BNP had significantly greater beneficial effects than systemic delivery&#46; It could be that a higher systemic dose is needed&#59; however&#44; the usage thereof would increase the incidence of adverse effects such as hypotension&#46;<a class="elsevierStyleCrossRefs" href="#bib0370"><span class="elsevierStyleSup">18&#44;40</span></a></p><p id="par0325" class="elsevierStylePara elsevierViewall">Furthermore&#44; it is worth noting that HF trials on nesiritide and dopamine have not been specific to patients exhibiting a resistance to loop diuretics&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">31</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">Vasopressin-2-receptor antagonists may promote aquaresis by blocking the effects of vasopressin on the vasopressin 2 receptors located in the collecting ducts&#44; thus blocking the re-absorption of free water&#46; This promotes water clearance without affecting sodium balance&#46; In the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan &#40;EVEREST&#41; trial&#44; tolvaptan at a dose of 30 mg once daily for a minimum of 60 days had no effect on total mortality or HF hospitalization when compared to placebo&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">21&#44;41</span></a></p><p id="par0335" class="elsevierStylePara elsevierViewall">Adenosine antagonists can potentially increase glomerular filtration and enhance the diuretic effect of diuretic drugs&#46; However&#44; the Placebo-Controlled Randomized Study of the Selective Adenosine A1 Receptor Antagonist Rolofylline for Patients Hospitalized with Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function &#40;PROTECT&#41; trial did not report any beneficial effects on congestion or renal function and was associated with an increased risk of seizures&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">21&#44;42</span></a></p><p id="par0340" class="elsevierStylePara elsevierViewall">Glucocorticoids may promote diuresis and protect renal function in patients with acute HF&#46; Liu et al&#46; reported the effects of prednisolone in 13 congestive HF patients with significant volume overload and diuretic resistance who had failed to respond to a conventional sequential nephron blockade treatment strategy&#46; They reported an improvement in diuresis&#44; clinical status and renal function&#46;<a class="elsevierStyleCrossRef" href="#bib0495"><span class="elsevierStyleSup">43</span></a> The same author later reviewed the available evidence and concluded that the short-term use of glucocorticoids&#44; when added to maximum conventional therapy&#44; can potentiate renal responsiveness to diuretic therapy in patients with HF&#46;<a class="elsevierStyleCrossRef" href="#bib0500"><span class="elsevierStyleSup">44</span></a> However&#44; larger randomized double-blind placebo-controlled studies are warranted to demonstrate their safety and efficacy in such patients&#46; The proposed mechanism of action of glucocorticoids includes increased expression of natriuretic peptide receptor-A in the kidney and the hypothalamus&#44; which appear to be reduced in patients with HF&#44; also increasing renal blood flow through dilatation of the renal vasculature via increased renal prostaglandin&#44; nitric oxide and dopamine production&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">21&#44;43&#44;44</span></a></p><p id="par0345" class="elsevierStylePara elsevierViewall">Levosimendan was studied in patients presenting with acute HF in the Randomized Multicenter Evaluation of Intravenous Levosimendan Efficacy &#40;REVIVE&#41; studies&#46; These showed that levosimendan improved renal function and diuretic response in such patients&#46; However&#44; there was also an increased risk of arrhythmia and hypotension&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a></p><p id="par0350" class="elsevierStylePara elsevierViewall">Ularitide&#44; a human endogenous natriuretic peptide expressed in the kidney&#44; which induces natriuresis and diuresis by binding to a specific natriuretic peptide receptor&#44; was investigated in patients with acute HF in the Efficacy and Safety of Ularitide for the Treatment of Acute Decompensated Heart Failure &#40;TRUE-AHF&#41; trial&#46; Packer et al&#46; reported favorable physiological effects &#40;greater reductions in systolic blood pressure and in levels of N-terminal pro&#8211;BNP &#91;NT-proBNP&#93; than the placebo group&#44; without affecting cardiac troponin levels&#41;&#46; However&#44; short-term treatment neither affected the initial 48-hour clinical course nor reduced long-term cardiovascular mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">21&#44;45</span></a></p><p id="par0355" class="elsevierStylePara elsevierViewall">In the Efficacy and Safety of Relaxin for the Treatment of Acute Heart Failure &#40;RELAX-AHF&#41; trial&#44; serelaxin&#44; a human recombinant form of the vasodilator relaxin&#44; showed no significant effect on diuretic response&#44; but did have beneficial effects in preventing organ damage in patients with acute HF who were diuretic-resistant&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">21&#44;46</span></a> The Efficacy&#44; Safety and Tolerability of Serelaxin When Added to Standard Therapy in AHF &#40;RELAX-AHF-2&#41; trial was designed to confirm serelaxin&#39;s effect on these clinical outcomes but it did not meet either of its primary endpoints&#46; There was no difference in cardiovascular mortality at 180 days and the trend for reducing worsening HF through day five with serelaxin was not statistically significant&#46;<a class="elsevierStyleCrossRef" href="#bib0515"><span class="elsevierStyleSup">47</span></a></p><p id="par0360" class="elsevierStylePara elsevierViewall">There are several other agents under investigation&#44; which could play a role in aiding decongestion of patients presenting with acute HF&#44; such as omecamtiv mecarbil and TRV027&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a></p><p id="par0365" class="elsevierStylePara elsevierViewall">Omecamtiv mecarbil is a selective cardiac myosin activator that increases myocardial function in healthy volunteers and in patients with chronic HF&#46; Its effects on patients with acute HF were evaluated in the Acute Treatment with Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure &#40;ATOMIC-HF&#41; trial&#46; This study showed that omecamtiv mecarbil may improve dyspnea scores when higher doses were used in comparison to placebo&#59; however&#44; it did not significantly improve overall dyspnea scores &#8211; the primary endpoint of the study&#46;<a class="elsevierStyleCrossRef" href="#bib0520"><span class="elsevierStyleSup">48</span></a></p><p id="par0370" class="elsevierStylePara elsevierViewall">TRV027 is a novel ligand of the angiotensin II type 1 receptor&#44; selectively antagonizing the negative effects of angiotensin II&#44; while preserving the potential pro-contractility effects of angiotensin II type 1 receptor stimulation&#46; Its safety and efficacy were assessed in the Biased ligand of the angiotensin II type 1 receptor in patients with acute heart failure &#40;BLAST-AHF&#41; trial and&#44; although well tolerated&#44; TRV027 did not improve clinical status through 30-day follow-up compared to placebo&#46;<a class="elsevierStyleCrossRef" href="#bib0525"><span class="elsevierStyleSup">49</span></a></p><p id="par0375" class="elsevierStylePara elsevierViewall">Further studies are needed to evaluate the safety and efficacy of these drug candidates in a larger group of patients with acute HF&#46;</p></span><span id="sec0105" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Ultrafiltration</span><p id="par0380" class="elsevierStylePara elsevierViewall">UF is very effective at removing plasma fluid from blood across a semipermeable membrane that allows small molecules to pass through along its pressure gradient to the ultrafiltrate fluid&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a></p><p id="par0385" class="elsevierStylePara elsevierViewall">Small studies suggest that UF improves pulmonary and peripheral edema&#44; lung function and hemodynamics without adverse effects on renal function&#46; The fluid removal rate is reevaluated using clinical assessment and serial hematocrit measurements to ensure appropriate vascular compartment refill&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a></p><p id="par0390" class="elsevierStylePara elsevierViewall">The recent development of veno-venous peripheral UF has positioned this technique as a potential alternative to loop diuretics in acute HF&#46;<a class="elsevierStyleCrossRef" href="#bib0385"><span class="elsevierStyleSup">21</span></a></p><p id="par0395" class="elsevierStylePara elsevierViewall">The Relief for Acutely Fluid-Overloaded Patients With Decompensated Congestive Heart Failure &#40;RAPID-CHF&#41; trial&#44; a multicenter randomized controlled trial involving forty patients&#44; found that UF was feasible&#44; well-tolerated&#44; and resulted in significant weight loss and fluid removal&#46;<a class="elsevierStyleCrossRef" href="#bib0530"><span class="elsevierStyleSup">50</span></a></p><p id="par0400" class="elsevierStylePara elsevierViewall">Favorable outcomes were also reported in the Ultrafiltration versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Congestive Heart Failure &#40;UNLOAD&#41; trial&#46; This prospective&#44; randomized&#44; multicenter trial involving 200 patients&#44; found that UF safely produces greater weight and fluid loss than intravenous diuretics&#44; reduces 90-day resource utilization for HF and is an effective alternative therapy&#46;<a class="elsevierStyleCrossRef" href="#bib0535"><span class="elsevierStyleSup">51</span></a></p><p id="par0405" class="elsevierStylePara elsevierViewall">In the Ultrafiltration vs&#46; Diuretics in Decompensated HF &#40;ULTRADISCO&#41; study&#44; a prospective&#44; randomized&#44; open-label&#44; single-center study which included 30 patients&#44; the use of UF was associated with greater hemodynamic stability and with a greater reduction in plasma levels of NT-proBNP and aldosterone compared to diuretic infusion&#46;<a class="elsevierStyleCrossRef" href="#bib0540"><span class="elsevierStyleSup">52</span></a></p><p id="par0410" class="elsevierStylePara elsevierViewall">In the Continuous Ultrafiltration for Congestive Heart Failure &#40;CUORE&#41; trial&#44; UF as a first-line treatment in patients with severe congestive HF was associated with prolonged clinical stabilization and greater freedom from rehospitalization for congestive HF compared to standard medical therapy alone&#46;<a class="elsevierStyleCrossRef" href="#bib0545"><span class="elsevierStyleSup">53</span></a></p><p id="par0415" class="elsevierStylePara elsevierViewall">The Cardiorenal Rescue Study in Acute Decompensated Heart Failure &#40;CARRESS-HF&#41;&#44; however&#44; found a stepped pharmacologic-therapy algorithm to be superior to UF for the preservation of renal function at 96 hours&#44; with a similar amount of weight loss seen with the two approaches and a higher rate of adverse events observed with UF&#46;<a class="elsevierStyleCrossRef" href="#bib0550"><span class="elsevierStyleSup">54</span></a></p><p id="par0420" class="elsevierStylePara elsevierViewall">Results of the Reverse Worsening Renal Function in Decompensated Heart Failure &#40;REWORD-HF&#41; study &#40;which ended in April 2017&#41; are still pending and will help determine whether fluid removal by UF is superior to different pharmacological approaches in acutely relieving congestion and preventing further deterioration in renal function and whether it results in longer admission-free survival 90 days after enrolment in patients with decompensated HF and cardiorenal syndrome&#46;</p><p id="par0425" class="elsevierStylePara elsevierViewall">Seven randomized controlled trials&#44; including several of those mentioned above&#44; were submitted for a meta-analysis&#46; UF was found to be an effective and safe therapeutic strategy&#44; resulting in greater weight loss and fluid removal without affecting renal function&#44; mortality or rehospitalization&#46;<a class="elsevierStyleCrossRef" href="#bib0555"><span class="elsevierStyleSup">55</span></a></p><p id="par0430" class="elsevierStylePara elsevierViewall">The 2016 European Society of Cardiology guidelines state that there is no evidence favoring UF over loop diuretics as first-line therapy in patients with acute HF&#46; The former should thus be confined to patients who fail to respond to diuretic-based strategies&#46;</p></span></span><span id="sec0110" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusion</span><p id="par0435" class="elsevierStylePara elsevierViewall">Diuretic resistance has emerged as an independent factor behind worse HF patient outcomes&#44; namely in-hospital worsening&#44; early post-discharge mortality and rehospitalizations&#46; While several mechanisms help to explain their reduced response to diuretics&#44; the definition of the problem itself remains elusive&#46; More recent evidence is leaning towards the coupling of parameters such as weight loss and urine output to diuretic dose&#44; but several challenges remain&#46; Non-pharmacological measures and a few medical options&#44; such as continuous infusion of diuretics and sequential nephron blockade&#44; may be used to overcome diuretic resistance&#46; Nevertheless&#44; disease progression may warrant more invasive methods for fluid removal&#46; Therapy must be tailored on a case-by-case basis&#46;</p></span><span id="sec0115" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Conflicts of interest</span><p id="par0440" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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          "identificador" => "sec0005"
          "titulo" => "Introduction"
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        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "Diuretic resistance &#8211; defining the problem"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Pharmacokinetics &#38; pharmacodynamics of loop diuretics"
        ]
        7 => array:3 [
          "identificador" => "sec0020"
          "titulo" => "Pathophysiology of diuretic resistance"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Reduced delivery of the diuretic to its site of action"
            ]
            1 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Neurohormonal activation"
            ]
            2 => array:2 [
              "identificador" => "sec0035"
              "titulo" => "Tubular compensatory readaptation"
            ]
            3 => array:2 [
              "identificador" => "sec0040"
              "titulo" => "Drug interactions"
            ]
          ]
        ]
        8 => array:3 [
          "identificador" => "sec0045"
          "titulo" => "Treatment options for diuretic resistance"
          "secciones" => array:12 [
            0 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Salt restriction"
            ]
            1 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Discontinue concomitant use of nonsteroidal anti-inflammatory drugs"
            ]
            2 => array:2 [
              "identificador" => "sec0060"
              "titulo" => "Establish the effective single dose"
            ]
            3 => array:2 [
              "identificador" => "sec0065"
              "titulo" => "Increase dose frequency of loop diuretics"
            ]
            4 => array:2 [
              "identificador" => "sec0070"
              "titulo" => "Diuretic substitution"
            ]
            5 => array:2 [
              "identificador" => "sec0075"
              "titulo" => "Intravenous diuretics"
            ]
            6 => array:2 [
              "identificador" => "sec0080"
              "titulo" => "Sequential nephron blockade"
            ]
            7 => array:2 [
              "identificador" => "sec0085"
              "titulo" => "Management of intra-abdominal pressure"
            ]
            8 => array:2 [
              "identificador" => "sec0090"
              "titulo" => "Infusion with albumin"
            ]
            9 => array:2 [
              "identificador" => "sec0095"
              "titulo" => "Renal-dose dopamine"
            ]
            10 => array:2 [
              "identificador" => "sec0100"
              "titulo" => "Alternative pharmacological therapies"
            ]
            11 => array:2 [
              "identificador" => "sec0105"
              "titulo" => "Ultrafiltration"
            ]
          ]
        ]
        9 => array:2 [
          "identificador" => "sec0110"
          "titulo" => "Conclusion"
        ]
        10 => array:2 [
          "identificador" => "sec0115"
          "titulo" => "Conflicts of interest"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1061248"
          "palabras" => array:5 [
            0 => "Heart failure"
            1 => "Diuretic resistance"
            2 => "Loop diuretic"
            3 => "Sequential nephron blockade"
            4 => "Ultrafiltration"
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        ]
      ]
      "pt" => array:1 [
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          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec1061249"
          "palabras" => array:5 [
            0 => "Insufici&#234;ncia card&#237;aca"
            1 => "Resist&#234;ncia aos diur&#233;ticos"
            2 => "Diur&#233;ticos de ansa"
            3 => "Bloqueio sequencial do nefr&#243;nio"
            4 => "Ultrafiltra&#231;&#227;o"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Heart failure is a disease with high direct and indirect costs&#46; Current treatment includes drugs that alter disease progression and drugs that to improve symptoms&#46; Loop diuretics are the cornerstone of congestion relief for acute management&#44; as well as for chronic stabilization&#46; In heart failure patients&#44; maximal diuretic response is reduced by many individual factors&#46; Diuretic resistance is defined as failure to achieve effective congestion relief despite appropriate or escalating diuretic doses&#46; Its causes include impaired delivery of the diuretic to its luminal site of action&#44; neurohormonal activation&#44; tubular compensatory adaptation and drug interactions&#46; Several strategies can be employed to aid decongestion of patients with impaired diuretic response&#46; These include salt restriction&#44; a higher effective single dose or higher dose frequency of loop diuretics&#44; continuous infusion of diuretics and&#47;or sequential nephron blockade through a synergistic combination of two or more diuretics from different classes&#46; Ultrafiltration has also been found to be another effective and safe therapeutic option and should be considered in patients with refractory diuretic resistance&#46; Overall&#44; there is a lack of high-quality clinical data to guide the choice of treatment strategy and therapy should be tailored on a case-by-case basis&#46;</p></span>"
      ]
      "pt" => array:2 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A insufici&#234;ncia card&#237;aca &#233; uma doen&#231;a com custos diretos e indiretos elevados&#46; A terap&#234;utica atual inclui f&#225;rmacos que alteram a progress&#227;o da doen&#231;a e f&#225;rmacos que melhoram a sintomatologia&#46; Os diur&#233;ticos de ansa constituem a pedra basilar no al&#237;vio da congest&#227;o quer na abordagem aguda quer na estabiliza&#231;&#227;o cr&#243;nica&#46; Nos doentes com insufici&#234;ncia card&#237;aca&#44; a resposta diur&#233;tica m&#225;xima encontra-se diminu&#237;da devido a m&#250;ltiplos fatores&#46; A resist&#234;ncia aos diur&#233;ticos &#233; definida como a aus&#234;ncia de al&#237;vio eficaz da congest&#227;o apesar de doses apropriadas ou crescentes de diur&#233;ticos&#46; As causas de resist&#234;ncia aos diur&#233;ticos incluem o compromisso da entrega de diur&#233;tico no seu local de a&#231;&#227;o&#44; a ativa&#231;&#227;o neuro-hormonal&#44; a adapta&#231;&#227;o compensat&#243;ria tubular e intera&#231;&#245;es medicamentosas&#46; Podem ser implementadas v&#225;rias estrat&#233;gias para diminuir a congest&#227;o em doentes com resposta diur&#233;tica insuficiente&#46; Essas estrat&#233;gias incluem restri&#231;&#227;o salina&#44; aumento da dose ou frequ&#234;ncia dos diur&#233;ticos de ansa&#44; infus&#227;o cont&#237;nua de diur&#233;ticos e&#47;ou bloqueio sequencial do nefr&#243;nio atrav&#233;s da combina&#231;&#227;o de dois ou mais diur&#233;ticos de diferentes classes e com efeitos sin&#233;rgicos&#46; A ultrafiltra&#231;&#227;o tem-se revelado uma outra estrat&#233;gia segura e eficaz e deve ser considerada em doentes com resist&#234;ncia aos diur&#233;ticos refrat&#225;ria&#46; Verifica-se globalmente uma escassez de dados cl&#237;nicos de elevada qualidade para guiar a escolha da estrat&#233;gia terap&#234;utica pelo que a abordagem deve ser adequada caso a caso&#46;</p></span>"
      ]
    ]
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      0 => array:3 [
        "identificador" => "nom0005"
        "titulo" => "<span class="elsevierStyleSectionTitle" id="sect0025">Abbreviations</span>"
        "listaDefinicion" => array:1 [
          0 => array:1 [
            "definicion" => array:25 [
              0 => array:2 [
                "termino" => "ATOMIC-HF"
                "descripcion" => "<p id="par0005" class="elsevierStylePara elsevierViewall">Acute Treatment with Omecamtiv Mecarbil to Increase Contractility in Acute Heart Failure</p>"
              ]
              1 => array:2 [
                "termino" => "BNP"
                "descripcion" => "<p id="par0010" class="elsevierStylePara elsevierViewall">B-type natriuretic peptide</p>"
              ]
              2 => array:2 [
                "termino" => "BLAST-AHF"
                "descripcion" => "<p id="par0015" class="elsevierStylePara elsevierViewall">Biased ligand of the angiotensin II type 1 receptor in patients with acute heart failure</p>"
              ]
              3 => array:2 [
                "termino" => "CARRESS-HF"
                "descripcion" => "<p id="par0020" class="elsevierStylePara elsevierViewall">Cardiorenal Rescue Study in Acute Decompensated Heart Failure</p>"
              ]
              4 => array:2 [
                "termino" => "CKD"
                "descripcion" => "<p id="par0025" class="elsevierStylePara elsevierViewall">Chronic kidney disease</p>"
              ]
              5 => array:2 [
                "termino" => "CUORE"
                "descripcion" => "<p id="par0030" class="elsevierStylePara elsevierViewall">Continuous Ultrafiltration for Congestive Heart Failure</p>"
              ]
              6 => array:2 [
                "termino" => "DOSE"
                "descripcion" => "<p id="par0035" class="elsevierStylePara elsevierViewall">Diuretic Optimization Strategies Evaluation</p>"
              ]
              7 => array:2 [
                "termino" => "DAD-HF II"
                "descripcion" => "<p id="par0040" class="elsevierStylePara elsevierViewall">Dopamine in Acute Decompensated Heart Failure II</p>"
              ]
              8 => array:2 [
                "termino" => "RELAX-AHF-2"
                "descripcion" => "<p id="par0045" class="elsevierStylePara elsevierViewall">Efficacy&#44; Safety and Tolerability of Serelaxin When Added to Standard Therapy in Acute Heart Failure</p>"
              ]
              9 => array:2 [
                "termino" => "RELAX-AHF"
                "descripcion" => "<p id="par0050" class="elsevierStylePara elsevierViewall">Efficacy and Safety of Relaxin for the Treatment of Acute Heart Failure</p>"
              ]
              10 => array:2 [
                "termino" => "TRUE-AHF"
                "descripcion" => "<p id="par0055" class="elsevierStylePara elsevierViewall">Efficacy and Safety of Ularitide for the Treatment of Acute Decompensated Heart Failure</p>"
              ]
              11 => array:2 [
                "termino" => "EVEREST"
                "descripcion" => "<p id="par0060" class="elsevierStylePara elsevierViewall">Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan</p>"
              ]
              12 => array:2 [
                "termino" => "EPICA"
                "descripcion" => "<p id="par0065" class="elsevierStylePara elsevierViewall">Epidemiologia da Insufici&#234;ncia Cardiaca e Aprendizagem</p>"
              ]
              13 => array:2 [
                "termino" => "HF"
                "descripcion" => "<p id="par0070" class="elsevierStylePara elsevierViewall">Heart failure</p>"
              ]
              14 => array:2 [
                "termino" => "NT-proBNP"
                "descripcion" => "<p id="par0075" class="elsevierStylePara elsevierViewall">N-terminal pro&#8211;BNP</p>"
              ]
              15 => array:2 [
                "termino" => "NSAID"
                "descripcion" => "<p id="par0080" class="elsevierStylePara elsevierViewall">Nonsteroidal anti-inflammatory drug</p>"
              ]
              16 => array:2 [
                "termino" => "PROTECT"
                "descripcion" => "<p id="par0085" class="elsevierStylePara elsevierViewall">Placebo-Controlled Randomized Study of the Selective Adenosine A1 Receptor Antagonist Rolofylline for Patients Hospitalized with Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function</p>"
              ]
              17 => array:2 [
                "termino" => "REVIVE"
                "descripcion" => "<p id="par0090" class="elsevierStylePara elsevierViewall">Randomized Multicenter Evaluation of Intravenous Levosimendan Efficacy</p>"
              ]
              18 => array:2 [
                "termino" => "RAPID-CHF"
                "descripcion" => "<p id="par0095" class="elsevierStylePara elsevierViewall">Relief for Acutely Fluid-Overloaded Patients With Decompensated Congestive Heart Failure</p>"
              ]
              19 => array:2 [
                "termino" => "ROSE"
                "descripcion" => "<p id="par0100" class="elsevierStylePara elsevierViewall">Renal Optimization Strategies Evaluation</p>"
              ]
              20 => array:2 [
                "termino" => "RAA"
                "descripcion" => "<p id="par0105" class="elsevierStylePara elsevierViewall">Renin-angiotensin-aldosterone</p>"
              ]
              21 => array:2 [
                "termino" => "REWORD-HF"
                "descripcion" => "<p id="par0110" class="elsevierStylePara elsevierViewall">Reverse Worsening Renal Function in Decompensated Heart Failure</p>"
              ]
              22 => array:2 [
                "termino" => "UF"
                "descripcion" => "<p id="par0115" class="elsevierStylePara elsevierViewall">Ultrafiltration</p>"
              ]
              23 => array:2 [
                "termino" => "UNLOAD"
                "descripcion" => "<p id="par0120" class="elsevierStylePara elsevierViewall">Ultrafiltration versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Congestive Heart Failure</p>"
              ]
              24 => array:2 [
                "termino" => "ULTRADISCO"
                "descripcion" => "<p id="par0125" class="elsevierStylePara elsevierViewall">Ultrafiltration vs&#46; Diuretics in Decompensated Heart Failure</p>"
              ]
            ]
          ]
        ]
      ]
    ]
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Pathophysiology-based approach to diuretic resistance&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Adapted from Verbrugge FH&#44; Mullens W &#38; Tang WH &#40;2016&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">13</span></a></p>"
          "tablatextoimagen" => array:1 [
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Author &#40;year&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Metric&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Findings in patients with low diuretic efficacy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Testani et al&#46; &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Net fluid loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher all-cause mortality after 5 years &#40;Penn Cohort&#41;&#47;180 days &#40;Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization Effectiveness Cohort&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Valente et al&#46; &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">5</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weight loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher heart failure readmissions after 60 days<br>Higher death&#44; heart failure or renal-related readmissions after 60 days<br>Higher all-cause mortality after 180 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Voors et al&#46; &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0390"><span class="elsevierStyleSup">22</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weight loss&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher death&#44; heart failure or renal-related readmissions after 60 days<br>Neutral effect on all-cause mortality after 180 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Singh et al&#46; &#40;2014&#41;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">12</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Urinary sodium<br>Furosemide concentration&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher death&#44; transplantation or heart failure readmission after 5 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">ter Maaten et al&#46; &#40;2015&#41;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">18</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Weight loss<br>Urine output&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher death or heart failure readmission after 30 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Verbrugge et al&#46; &#40;2015&#41;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Natriuresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher death or heart failure readmission after 188 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kumar et al&#46; &#40;2015&#41;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Fractional sodium excretion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher all-cause mortality after 30 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Ter Maaten et al&#46; &#40;2016&#41;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">20</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Chloride levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher mortality through 180 days&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Aronson et al&#46; &#40;2016&#41;<a class="elsevierStyleCrossRef" href="#bib0560"><span class="elsevierStyleSup">56</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Net fluid loss<br>Urine output&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Higher all-cause mortality after 6 months&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Adapted from Hoorn EJ &#38; Ellison DH &#40;2017&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0460"><span class="elsevierStyleSup">36</span></a></p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Incorrect diagnosis</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Venous edema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Lymphatic edema&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Third space overload with intravascular volume depletion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Nonadherence to recommended sodium and&#47;or fluid restriction</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Poor diuretic delivery to the nephron lumen</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nonadherence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dose too low or too infrequent&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Poor absorption &#40;example&#58; edematous gut&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypoalbuminemia and nephrotic syndrome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hepatic cirrhosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Reduced diuretic secretion</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tubular uptake of diuretic impaired by uremic toxins&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Decreased kidney blood flow&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Decreased functional kidney mass&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Insufficient kidney response to drug</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Low glomerular filtration rate&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Decreased effective intravascular volume despite elevated total extracellular fluid volume&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Activation of the renin-angiotensin-aldosterone axis and renal sympathetic nerves&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Increased sodium delivery and absorption in distal tubular segments&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Compensatory retention of sodium after the effective period of the diuretic&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nephron adaptation &#40;hypertrophy and hyperplasia of distal tubular cells&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Use of nonsteroidal anti-inflammatory drugs&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Causes of diuretic resistance&#46;</p>"
        ]
      ]
      3 => array:8 [
        "identificador" => "tbl0015"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at3"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Adapted from Bowman&#44; Nawarskas &#38; Anderson &#40;2016&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0435"><span class="elsevierStyleSup">31</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Strategy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Summary of evidence&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Recommendation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Initial measures</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Intravenous diuretics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Improved pharmacokinetics in compensated heart failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Initial measure in hospitalized patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Increase diuretic dose&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Doses of &#8805;500 mg&#47;day of oral furosemide were safe<br>High intravenous doses were safe and were more effective&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consider in mildly symptomatic ambulatory patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Use alternative loop diuretic &#40;bumetanide and torsemide&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Greater enteral absorption and less affected by edematous states&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consider in case of poor response to oral furosemide<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Continuous infusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Lower total daily doses to elicit the same degree of natriuresis compared to bolus doses without better symptom relief or creatinine improvements&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consider in case of inadequate response to bolus doses&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Combination of intravenous loop diuretics with one or more diuretics from different classes&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Thiazide&#47;Metolazone &#8211; Increased urine sodium and&#47;or weight loss<br>- Acetazolamide &#8211; increased diuresis<br>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consider in case of inadequate response to increasing doses of IV loop diuretics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">- Mineralocorticoid receptor antagonist &#8211; increased diuresis and faster symptom relief&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consider in ambulatory or outpatients with an inadequate response to loop diuretics&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="3" align="left" valign="top"><span class="elsevierStyleItalic">Advanced measures</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hypertonic saline infusion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Improved diuresis and renal function&#44; and shortened hospitalizations&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consider when the above options have failed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Dopamine&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Similar urine output when added to low-dose intravenous furosemide compared with high-dose intravenous furosemide alone<br>Subsequent trials have failed to demonstrate a benefit&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Consider only when all other options have failed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Nesiritide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">No improvement in urine output&#44; hospital readmission or mortality&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Should not be used in loop diuretic resistance&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Strategies for treating diuretic resistance&#46;</p>"
        ]
      ]
      4 => array:8 [
        "identificador" => "tbl0020"
        "etiqueta" => "Table 4"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at4"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Adapted from Brater &#40;2011&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0455"><span class="elsevierStyleSup">35</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td-with-role" title="table-head ; entry_with_role_rowhead " align="left" valign="top" scope="col">Creatinine clearance &#40;ml&#47;min&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col">Loading dose &#40;mg&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " colspan="3" align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Infusion rate &#40;mg&#47;h&#41;</th></tr><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">All levels&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#60;25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">25-75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#62;75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Furosemide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">20 then 40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 then 20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Bumetanide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">1 then 2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">0&#46;5 then 1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Torsemide&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">10 then 20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">5 then 10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab1922124.png"
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Dosage regimens for continuous intravenous diuretic administration&#46;</p>"
        ]
      ]
      5 => array:8 [
        "identificador" => "tbl0025"
        "etiqueta" => "Table 5"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at5"
            "detalle" => "Table "
            "rol" => "short"
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        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Adapted from Ellison &#40;2001&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">8</span></a></p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">To an effective or maximal safe dose of a loop diuretic add&#58;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Distal convoluted tubule diuretics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Metolazone 2&#46;5-10 mg per os daily &#40;duration or frequency adjusted based on the target weight&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Hydrochlorothiazide &#40;or equivalent&#41; 25-100 mg per os daily&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Chlorothiazide 500-1000 mg intravenously&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Proximal tubule diuretics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Acetazolamide 250-375 mg daily or up to 500 mg intravenously&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Potassium-sparing diuretics</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Spironolactone 100-200 mg daily&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Amiloride 5-10 mg daily&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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Article information

ISSN: 21742049
Original language: English

DOI:10.1016/j.repce.2018.03.021

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Year/Month	Html	Pdf	Total

2024 November	23	5	28
2024 October	134	61	195
2024 September	154	52	206
2024 August	83	48	131
2024 July	86	54	140
2024 June	63	27	90
2024 May	98	45	143
2024 April	57	41	98
2024 March	82	31	113
2024 February	51	27	78
2024 January	83	32	115
2023 December	68	38	106
2023 November	78	32	110
2023 October	71	32	103
2023 September	66	25	91
2023 August	49	23	72
2023 July	59	12	71
2023 June	51	18	69
2023 May	90	33	123
2023 April	71	18	89
2023 March	114	30	144
2023 February	100	21	121
2023 January	76	20	96
2022 December	81	35	116
2022 November	86	35	121
2022 October	55	33	88
2022 September	95	52	147
2022 August	102	48	150
2022 July	104	48	152
2022 June	74	36	110
2022 May	86	30	116
2022 April	86	39	125
2022 March	57	37	94
2022 February	55	39	94
2022 January	74	18	92
2021 December	55	35	90
2021 November	72	37	109
2021 October	116	57	173
2021 September	79	42	121
2021 August	90	52	142
2021 July	62	44	106
2021 June	76	37	113
2021 May	137	45	182
2021 April	427	158	585
2021 March	387	82	469
2021 February	243	62	305
2021 January	175	46	221
2020 December	163	56	219
2020 November	137	38	175
2020 October	100	37	137
2020 September	74	14	88
2020 August	43	24	67
2020 July	43	21	64
2020 June	33	9	42
2020 May	33	8	41
2020 April	32	10	42
2020 March	40	18	58
2020 February	116	19	135
2020 January	59	17	76
2019 December	37	9	46
2019 November	21	11	32
2019 October	17	3	20
2019 September	34	8	42
2019 August	17	13	30
2019 July	10	8	18
2019 June	19	23	42
2019 May	21	9	30
2019 April	20	16	36
2019 March	11	17	28
2019 February	17	11	28
2019 January	31	17	48
2018 December	9	14	23

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