#158 Diuretics Resistance Cases

Diuretic resistance in patients with cardiorenal syndrome often stems from underlying hemodynamic issues rather than primary medication failure. Nephrologist Dr. Nayan Arora emphasizes that clinicians must prioritize optimizing renal blood flow—the "flow first, diuretics second" approach—before escalating diuretic dosages. Clinical cases illustrate this principle: relieving intra-abdominal hypertension via paracentesis can resolve acute kidney injury, while inotropic support or vasopressin may be necessary to improve renal perfusion pressure in patients with low cardiac output or right heart failure. Even when mean arterial pressure appears normal, shifting the renal autoregulatory curve requires targeted interventions to restore adequate diuresis. Ultimately, when standard diuretic protocols fail, clinicians should investigate hemodynamics, such as right atrial pressure or cardiac index, to identify and treat the specific physiological barriers preventing effective volume management.