Serviço de Nefrologia, Hospital Dr. Nélio Mendonça, Funchal, Portugal.
Serviço de Nefrologia, Hospital de Santa Cruz, Carnaxide, Portugal.
Rev Port Cardiol. 2023 Sep;42(9):797-803. doi: 10.1016/j.repc.2022.05.012. Epub 2023 Mar 21.
Acute heart failure (HF) decompensation generally manifests with signs and symptoms of congestion that strongly predict poor poor patient outcome. Loop diuretics are the cornerstone of therapy to counteract fluid overload and are widely used for acute management and chronic stabilization of HF. However, a diminished response to loop diuretics is a common problem, affecting the patient's clinical course and potentially prolonging hospitalization. Diuretic resistance is defined as failure to decongest despite appropriate and escalating loop diuretic therapy. We propose a protocol for the management of diuretic resistance. The initial approach should include an assessment of causes of pseudo-diuretic resistance. Adjustments to loop diuretic therapy, such as increasing doses and frequency of administration and sequential nephron blockade, may be successful. For hospitalized patients with progressive disease there are more invasive methods for fluid removal. Switching from oral to intravenous loop diuretics is essential to avoid variable absorption and for symptomatic relief. Extracorporeal ultrafiltration is also an option since this technique is highly effective at removing plasma fluid from blood. While extracorporeal ultrafiltration is an invasive solution, peritoneal dialysis is a home-based, intermittent therapeutic option that can enable efficient management of fluid overload, preventing HF-related hospital admission, and improving quality of life. As a last resort for fluid removal, a peritoneal dialysis regimen should fully exploit its decongestive properties and should be tailored to the patient's characteristics and clinical needs.
急性心力衰竭（HF）失代偿通常表现为充血的体征和症状，这些症状强烈预示着患者预后不良。袢利尿剂是对抗液体超负荷的治疗基石，广泛用于急性管理和 HF 的慢性稳定。然而，对袢利尿剂的反应减弱是一个常见问题，影响患者的临床病程并可能延长住院时间。利尿剂抵抗是指尽管进行了适当和逐渐增加的袢利尿剂治疗，但仍无法消除充血。我们提出了一种治疗利尿剂抵抗的方案。初始方法应包括评估假性利尿剂抵抗的原因。调整袢利尿剂治疗，例如增加剂量和给药频率以及顺序肾单位阻断，可能会成功。对于病情进展的住院患者，有更多的侵入性方法来去除液体。从口服转为静脉袢利尿剂是必要的，以避免吸收的变异性并缓解症状。体外超滤也是一种选择，因为这种技术非常有效地从血液中去除血浆液体。虽然体外超滤是一种侵入性的解决方案，但腹膜透析是一种基于家庭的间歇性治疗选择，可以有效地管理液体超负荷，防止与 HF 相关的住院，并提高生活质量。作为去除液体的最后手段，腹膜透析方案应充分利用其充血性特性，并应根据患者的特点和临床需求进行调整。
