Review examines kidney dysfunction and diuretic resistance in acute decompensated heart failure

A review in the Clinical Journal of the American Society of Nephrology examines kidney dysfunction and diuretic resistance in acute decompensated heart failure (ADHF). The authors describe reduced estimated glomerular filtration rate below 60 ml/min per 1.73 m² or poor urinary response to diuretics as markers associated with mortality and adverse cardiovascular events. This is a review, not a new patient study; the supplied abstract provides no pooled effect estimates.

Low cardiac output, arterial underfilling, and venous congestion may interact with neurohormonal activation, inflammation, and endothelial dysfunction to impair kidney function. Therapies targeting cardiovascular hemodynamics have not consistently improved kidney function. For persistent congestion and diuretic resistance, the review discusses escalating loop diuretics, combining diuretics that target different nephron segments, and monitoring urinary response to guide titration.

Hospitalization also offers an opportunity to initiate or resume guideline-directed medical therapy, which remains underused despite cardiovascular benefits. The authors caution that acute kidney function declines during decongestion or treatment initiation can be misleading when considered in isolation. Emerging approaches aim to relieve congestion without worsening kidney function, but the supplied material provides no quantitative efficacy or safety results for these strategies.