2025 HFSA Contemporary Issues in Heart Failure - OnDemand-Management of Fluid Overload and Renal Dysfunction (Part 1)

Video Transcription

Video Summary

This talk reviews managing fluid overload and renal dysfunction in acute heart failure (HF), focusing on diuresis strategies. Most HF hospitalizations are due to congestion, and while relieving congestion improves symptoms, its impact on long-term outcomes remains unclear. Recent randomized trials showed no significant survival benefit from aggressive diuretic use despite better fluid removal, complicating management decisions. The speaker emphasizes that achieving euvolemia—optimal fluid balance—is the main goal but is difficult to measure and often unachievable with current tools. Creatinine rises during diuresis often reflect functional changes rather than true kidney injury and should be carefully monitored but not necessarily feared. Diuretic resistance is nearly universal in HF due to tubular kidney adaptations, primarily distal nephron sodium reabsorption, requiring careful dose titration often well beyond standard doses. Loop diuretics have a dose-response curve where large dose increases yield modest urine output gains, but overdosing is relatively safe. Yale’s nurse-driven diuretic titration pathway uses sodium excretion, rather than fluid loss alone, to guide dosing more precisely and has shown improved fluid removal and safety. The approach leverages timely adjustments, frequent dosing, and better markers to overcome resistance and optimize decongestion. The talk concludes by inviting viewers to part two for further discussion.

Keywords

acute heart failure

fluid overload

renal dysfunction

diuresis strategies

euvolemia

diuretic resistance

nurse-driven diuretic titration