Diuresis in Resistant Congestion, Desperate Measures Before Ultrafiltration

Author : H. Susilo, M.Y. Alsagaff
Upload Date : 19-04-2018

Introduction: Impaired diuretic response is a common problem in patients with acute heart failure. An enhanced understanding of diuretic response should ultimately lead to improved individualized approaches to treating patients with acute heart failure.

Objective: The purpose of this case report is to present a patient with cardiorenal syndrome type I that is resistant to initial loading of diuretic thus requiring high dose diuretic therapy.

Case Illustration: A male, 48 yo, complained of shortness of breath with history of diabetes and uncontrolled hypertension. The patient was anemic, had jugular venous distention, bilateral basal rales, ascites, bilateral leg edema, cold extremities. Chest X ray showed cardiomegaly, pulmonary congestion, left-sided pleural effusion. Echocardiography showed LV dilatation (LVIDd 5.9 cm), decreased LV systolic function (EF by TEICH 30%), akinesia of the anterior wall (BMA), concentric LVH. Initial laboratory tests showed anemia (HB: 9.5), impaired renal function (SC: 5.17), hypoalbuminemia (2.95). The patient was diagnosed as Ischemic Cardiomyopathy accompanied by Cardiorenal Syndrome Type I, Anemia, Hypoalbuminemia, Pleural Effusion, Type 2 Diabetes Mellitus. The patient was given intravenous injection of 40 mg followed by 80 mg furosemide and low dose dobutamine pump. As there was no urine production, the patient was given 160 mg furosemide injection followed by furosemide pump of 15 mg/hr. After the administration of high-dose furosemide, there were increased urine production and improved signs and symptoms.

Discussion: Diuretic resistance is defined as persistent congestion despite adequate and escalating doses of diuretic with >80 mg furosemide/day. Several treatment strategies include increased dose of intravenous loop diuretics, combination therapy, and ultrafiltration.

Conclusion: We reported a patient with Ischemic Cardiomyopathy accompanied by Cardiorenal Syndrome Type I that was not improved with initial loading of diuretic so high dose intravenous loop diuretic was performed without the need of ultrafiltration.

KEYWORDS : Initial loading, resistant congestion, ultrafiltration

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