Continuing long-term diuretic therapy

Abstract

The practical aspects of prescribing diuretic therapy in chronic kidney disease, diabetes mellitus and heart failure, both as separate nosologies and in their combination, are considered. Although these diseases have different etiologies, chronic fluid retention is a common manifestation as they progress. Since 2020, combined diuretic therapy with an aldosterone antagonist and a loop diuretic has been supplemented with sodium-glucose cotransporter-2 inhibitor for chronic kidney disease, diabetes mellitus and chronic heart failure with reduced ejection fraction. This approach demonstrates better dehydration, increased patient survival, and reduced cardiovascular mortality. However, a decrease in the glomerular filtration rate is accompanied by a decrease in the effectiveness of these agents. This border line is glomerular filtration rate less than 30 ml/min/m2, although there are individual differences. A possible solution for the individualization of the continuation of triple long-term diuretic therapy is to determine the functional renal reserve. Its maintenance and control of blood potassium allows the triple therapy to be continued. Otherwise, the patient needs to cancel an aldosterone antagonist and sodium-glucose cotranspor­ter-2 inhibitor, switch from torasemide to furosemide and prepare for renal replacement therapy.