Journal
KIDNEY360
Volume 3, Issue 5, Pages 954-967Publisher
AMER SOC NEPHROLOGY
DOI: 10.34067/KID.0006372021
Keywords
nephropharmacology; acute heart failure; cardiorenal syndrome; diuretic resistance; diuretics; loop diuretic
Categories
Funding
- National Institutes of Health (NIH)/National Heart, Lung, and Blood Institute [R01HL139629, R21HL143092, R01HL128973, R01HL148354, P30DK079310]
- National Institute of Diabetes and Digestive and Kidney Disease [P30DK079310]
- National Center for Advancing Translational Science, a component of the NIH [UL1 TR000142]
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Despite incomplete understanding of the causes and mechanisms of cardiorenal syndrome, renal sodium retention plays a significant role in driving congestive heart failure and determining the response to diuretic therapy. Recent studies have challenged classical diuretic resistance mechanisms and proposed new categorizations for therapeutic strategies in cardiorenal syndrome.
Despite the incompletely understood multiple etiologies and underlying mechanisms, cardiorenal syndrome is characterized by decreased glomerular filtration and sodium avidity. The underlying level of renal sodium avidity is of primary importance in driving a congested heart failure phenotype and ultimately determining the response to diuretic therapy. Historically, mechanisms of kidney sodium avidity and resultant diuretic resistance were primarily extrapolated to cardiorenal syndrome from non?heart failure populations. Yet, the mechanisms appear to differ between these populations. Recent literature in acute decompensated heart failure has refuted several classically accepted diuretic resistance mechanisms and reshaped how we conceptualize diuretic resistance mechanisms in cardiorenal syndrome. Herein, we propose an anatomically based categorization of diuretic resistance mechanisms to establish the relative importance of specific transporters and translate findings toward therapeutic strategies. Within this categorical structure, we discuss classic and novel mechanisms of diuretic resistance.
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