Diuretic therapy in acute decompensated heart failure

Episodes of congestion characterize the disease course of patients with heart failure, resulting in a high morbidity with the need for urgent hospitalization. The main treatment goal is to alleviate signs and symptoms of congestion to reach euvolemia. Loop diuretics remain the cornerstone in the treatment, however diuretic response is unpredictable and therapy should be individualized. The neurohormonal activation result in an increased sodium reabsorption along the whole nephron. Each segment provides a different target site to increase diuretic and natriuretic response. This manuscript provides further insight in the pathophysiology behind the cardiorenal interactions, which lead to the increased sodium avidity in heart failure. In addition, the different therapeutic options to enhance diuretic response in patients with acute heart failure is discussed, as well as the assessment of the diuretic response based on the urinary sodium concentration.