The pathophysiology and management of diuretic resistance in patients with heart failure

Hosp Pract (1995). 2022 Apr;50(2):93-101. doi: 10.1080/21548331.2021.1893065. Epub 2021 Apr 12.


Objectives: The objectives of the study are to investigate the causes of diuretic resistance in patients with advanced congestive heart failure (CHF), since diuretics are the cornerstone of treatment of these patients. Several studies have shown that diuretic resistance in patients with advanced CHF is common, ranging from 25% to 50% in hospitalized patients.

Methods: In order to get a current perspective as to the magnitude of diuretic resistance in such patients, a focused Medline search of the English language literature was conducted between 2015 and 2020 using the search terms, CHF, diuretics, treatment, resistance, frequency, and 30 papers with pertinent information were selected.

Results: The analysis of data from the selected papers demonstrated that diuretic resistance is common in hospitalized patients with advanced CHF and frequently associated with renal failure, which is secondary to CHF.

Conclusions: Diuretic resistance appears to be common in patients with advanced CHF and it is mostly due to decreased cardiac output, low blood pressure, decreased glomerular filtration rate, decreased filtration of sodium, and increased tubular reabsorption of sodium. Diuretic resistance in such patients can be overcome with the combination of loop diuretics with thiazide and thiazide-like diuretics, aldosterone antagonists, as well as other agents. The data from these studies in combination with collateral literature will be discussed in this review.

Keywords: Congestive heart failure; diuretic combinations; diuretics; renal failure; resistance; treatment.

Publication types

  • Review

MeSH terms

  • Diuretics* / adverse effects
  • Diuretics* / therapeutic use
  • Heart Failure*
  • Humans
  • Sodium
  • Thiazides


  • Diuretics
  • Thiazides
  • Sodium