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Wilcox CS, Testani JM, Pitt B. Pathophysiology of Diuretic Resistance and Its Implications for the Management of Chronic Heart Failure. Hypertension 2020; 76:1045-1054. [PMID: 32829662 PMCID: PMC10683075 DOI: 10.1161/hypertensionaha.120.15205] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Diuretic resistance implies a failure to increase fluid and sodium (Na+) output sufficiently to relieve volume overload, edema, or congestion, despite escalating doses of a loop diuretic to a ceiling level (80 mg of furosemide once or twice daily or greater in those with reduced glomerular filtration rate or heart failure). It is a major cause of recurrent hospitalizations in patients with chronic heart failure and predicts death but is difficult to diagnose unequivocally. Pharmacokinetic mechanisms include the low and variable bioavailability of furosemide and the short duration of all loop diuretics that provides time for the kidneys to restore diuretic-induced Na+ losses between doses. Pathophysiological mechanisms of diuretic resistance include an inappropriately high daily salt intake that exceeds the acute diuretic-induced salt loss, hyponatremia or hypokalemic, hypochloremic metabolic alkalosis, and reflex activation of the renal nerves. Nephron mechanisms include tubular tolerance that can develop even during the time that the renal tubules are exposed to a single dose of diuretic, or enhanced reabsorption in the proximal tubule that limits delivery to the loop, or an adaptive increase in reabsorption in the downstream distal tubule and collecting ducts that offsets ongoing blockade of Na+ reabsorption in the loop of Henle. These provide rationales for novel strategies including the concurrent use of diuretics that block these nephron segments and even sequential nephron blockade with multiple diuretics and aquaretics combined in severely diuretic-resistant patients with heart failure.
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Affiliation(s)
- Christopher Stuart Wilcox
- From the Division of Nephrology and Hypertension and Hypertension Center, Georgetown University, Washington DC (C.S.W.)
| | | | - Bertram Pitt
- Division of Cardiology, University of Michigan, Ann Arbor, MI (B.P.)
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Prieto-García L, Pericacho M, Sancho-Martínez SM, Sánchez Á, Martínez-Salgado C, López-Novoa JM, López-Hernández FJ. Mechanisms of triple whammy acute kidney injury. Pharmacol Ther 2016; 167:132-145. [PMID: 27490717 DOI: 10.1016/j.pharmthera.2016.07.011] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Accepted: 07/16/2016] [Indexed: 12/26/2022]
Abstract
Pre-renal acute kidney injury (AKI) results from glomerular haemodynamic alterations leading to reduced glomerular filtration rate (GFR) with no parenchymal compromise. Renin-angiotensin system inhibitors, such as angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor antagonists (ARAs), non-steroidal anti-inflammatory drugs (NSAIDs) and diuretics, are highly prescribed drugs that are frequently administered together. Double and triple associations have been correlated with increased pre-renal AKI incidence, termed "double whammy" and "triple whammy", respectively. This article presents an integrative analysis of the complex interplay among the effects of NSAIDs, ACEIs/ARAs and diuretics, acting alone and together in double and triple therapies. In addition, we explore how these drug combinations alter the equilibrium of regulatory mechanisms controlling blood pressure (renal perfusion pressure) and GFR to increase the odds of inducing AKI through the concomitant reduction of blood pressure and distortion of renal autoregulation. Using this knowledge, we propose a more general model of pre-renal AKI based on a multi whammy model, whereby several factors are necessary to effectively reduce net filtration. The triple whammy was the only model associated with pre-renal AKI accompanied by a course of other risk factors, among numerous potential combinations of clinical circumstances causing hypoperfusion in which renal autoregulation is not operative or is deregulated. These factors would uncouple the normal BP-GFR relationship, where lower GFR values are obtained at every BP value.
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Affiliation(s)
- Laura Prieto-García
- Instituto de Estudios de Ciencias de la Salud de Castilla y León-Instituto de Investigación Biomédica de Salamanca (IECSCYL-IBSAL), Paseo de San Vicente, 58-182 - Hospital Virgen Vega, Planta 10, 37007 Salamanca, Spain; Department of Physiology & Pharmacology, University of Salamanca, Salamanca, Spain; Instituto Reina Sofía de Investigación Nefrológica, Fundación Iñigo Álvarez de Toledo, Madrid, Spain; Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Group of Theranostics for Renal and Cardiovascular Diseases (TERCARD), Edificio Departamental, Campus Miguel de Unamuno, Salamanca, Spain
| | - Miguel Pericacho
- Instituto de Estudios de Ciencias de la Salud de Castilla y León-Instituto de Investigación Biomédica de Salamanca (IECSCYL-IBSAL), Paseo de San Vicente, 58-182 - Hospital Virgen Vega, Planta 10, 37007 Salamanca, Spain; Department of Physiology & Pharmacology, University of Salamanca, Salamanca, Spain; Instituto Reina Sofía de Investigación Nefrológica, Fundación Iñigo Álvarez de Toledo, Madrid, Spain
| | - Sandra M Sancho-Martínez
- Department of Physiology & Pharmacology, University of Salamanca, Salamanca, Spain; Instituto Reina Sofía de Investigación Nefrológica, Fundación Iñigo Álvarez de Toledo, Madrid, Spain; Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Group of Theranostics for Renal and Cardiovascular Diseases (TERCARD), Edificio Departamental, Campus Miguel de Unamuno, Salamanca, Spain
| | - Ángel Sánchez
- Instituto de Estudios de Ciencias de la Salud de Castilla y León-Instituto de Investigación Biomédica de Salamanca (IECSCYL-IBSAL), Paseo de San Vicente, 58-182 - Hospital Virgen Vega, Planta 10, 37007 Salamanca, Spain; Hospital Universitario de Salamanca, Unidad de Hipertensión, Salamanca, Spain
| | - Carlos Martínez-Salgado
- Instituto de Estudios de Ciencias de la Salud de Castilla y León-Instituto de Investigación Biomédica de Salamanca (IECSCYL-IBSAL), Paseo de San Vicente, 58-182 - Hospital Virgen Vega, Planta 10, 37007 Salamanca, Spain; Department of Physiology & Pharmacology, University of Salamanca, Salamanca, Spain; Instituto Reina Sofía de Investigación Nefrológica, Fundación Iñigo Álvarez de Toledo, Madrid, Spain; Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Group of Theranostics for Renal and Cardiovascular Diseases (TERCARD), Edificio Departamental, Campus Miguel de Unamuno, Salamanca, Spain
| | - José Miguel López-Novoa
- Instituto de Estudios de Ciencias de la Salud de Castilla y León-Instituto de Investigación Biomédica de Salamanca (IECSCYL-IBSAL), Paseo de San Vicente, 58-182 - Hospital Virgen Vega, Planta 10, 37007 Salamanca, Spain; Department of Physiology & Pharmacology, University of Salamanca, Salamanca, Spain; Instituto Reina Sofía de Investigación Nefrológica, Fundación Iñigo Álvarez de Toledo, Madrid, Spain; Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Group of Theranostics for Renal and Cardiovascular Diseases (TERCARD), Edificio Departamental, Campus Miguel de Unamuno, Salamanca, Spain
| | - Francisco J López-Hernández
- Instituto de Estudios de Ciencias de la Salud de Castilla y León-Instituto de Investigación Biomédica de Salamanca (IECSCYL-IBSAL), Paseo de San Vicente, 58-182 - Hospital Virgen Vega, Planta 10, 37007 Salamanca, Spain; Department of Physiology & Pharmacology, University of Salamanca, Salamanca, Spain; Instituto Reina Sofía de Investigación Nefrológica, Fundación Iñigo Álvarez de Toledo, Madrid, Spain; Group of Biomedical Research in Critical Care Medicine (BioCritic), Hospital Clínico Universitario de Valladolid, Valladolid, Spain; Group of Theranostics for Renal and Cardiovascular Diseases (TERCARD), Edificio Departamental, Campus Miguel de Unamuno, Salamanca, Spain.
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