Treatment with diuretics must be started only in case of fluid retention findings. The symptoms and signs have been described in different sources.
It should be taken into consideration that if the above-mentioned findings have been developed within 1-3 days and combine with tachycardia, hypotonia so the status must be considered as an acutely decompensated heart failure. In this situation the suggested algorithm cannot be used and the efficient outpatient management is usually impossible.
In case of FRS as a result of chronic heart failure (CHF) the diuretics application should be combined with ACE inhibitors or (in case of the intolerability) All-receptor blockers, p-adrenoreceptor blockers and mineralocorticoid receptor antagonists (MCRA).
The most important in diuretic application in FRS is the continuous mode of usage. The diuretics should be taken daily. Discrete courses may cause the neurohormone systems hyperactivation and the FRS progression.
Treatment with diuretics should be performed under daily weight control. The recommended maximum of weight loss according to the diagnosis and treatment guidelines for chronic heart failure (CHF) composes up to 1 kg per day and should be reduced outpatiently to 0.5-0.7 kg per day for the sake of safety. Dehydration and overdiuresis may be more dangerous than edema syndrome.
Diuretic application and dose titration for increasing demand the mandatory control of electrolyte plasma level, glomerular filtration rate (GFR), oT-interval size at least once a week. After status stabilization the potassium and creatinine /GFR values should be controlled once in 3-6 months.
By reaching clinical effect (FRS improvement and increasing physical activity tolerance) it is necessary to start diuretic dose titration for reducing under daily weight control. In few cases after stabilization the drug can be completely cancelled in some weeks (when regular medical status observation possible).
Performing the active diuretic treatment one should remember about some salt-water mode particularities. Optimum diuresis can be achieved if the diuretic treatment is combined with the dietary with usual sodium amount and slight reduce of drinking water volume (1-1.2 liter per day). During active diuretic treatment the water limitation is more reasonable than strong reduce of salt use.
Diuretic administration algorithm in the FRS outpatient practice
If FRS has caused slight physical limitation (II functional class of CHF), the right choice of a diuretic requires a correct assessment of kidney function and background therapy.
The treatment should be started with initial dose of loop diuretics (LD). The thiazide diuretics (TD) application should be continued in case of the FRS appearance in patients with hypertension and normal renal function and these drugs have been used earlier. The only combination of TD with ACE inhibitors or ARA should be considered as a safe therapy. The drug dose is especially important. The hydrochlorthiazide application in dose 25 mg and higher is recommended for CHF treatment. In this dose range it can result in strong metabolic disorders, in particular hypokalemia, hyponatremia, new cases of diabetus mellitus. The hypothiazide in dose of 12.5 mg per day in a routine combination with ACE inhibitors and/or ARA as an antihypertensive agent has mild diuretic effect. Unfortunately, other TD (chlortalidone, metalasone) with stronger and longer diuretic effects are not registered. Furthermore the TD usage in purpose of ecuresis is associated with a higher probability of hypertension than LD. It is known that the pressure decrease is an independent factor for poor prognosis in CHF patients, the main reason for FRS development. It should be particularly noted that the TD efficiency decreases even in moderate chronic kidney disease (CKD), and GFR < 30 ml/min/1.73 m 2 should be considered as an absolute contradictory for its application.
The all above-mentioned conditions significantly reduce the TD usage in current FRS treatment patterns. They may be included to the combined diuretic therapy in the case of the LD high dose insufficiency. However one should remember that such treatment requires daily electrolyte control in the first instance because of the high risk for hypokalemia that is difficult for performing in the outpatient setting.
If a patient has strong restrictions in physical activity or clinical symptoms of FRS manifest at rest (III-IV FC), the diuretic therapy should be begun with a LD started dose. The preference should be taken to the loop diuretics with long half-life period and predictable absorption from gastrointestinal tract. Prolongating the interval of the diuretic molecule release achieved through a special matrix usage decreases a peak concentration and elongates the time of reaching a peak concentration in plasma. Thereby their rules for the thiazide diuretic application (torasemide with modified release) administration acts a gentler and more predictable diuretic effect and impairs the life quality of a patient to a lesser degree. Furthermore the torasemide with modified release reduces the risk of a pike – if they have been using as a partshaped natriuresis development, which may cause renal tubule damage and compensatory activation of SAS and RAAS and diuretic and rehypertension duce diuretic treatment efficiency.
The insufficiency of the all mentioned measurements demands the assessment of possible diuretic refractivity reasons.
The next FRS treatment with diuretics step should include diuretic intravenous bolus injections and drop infusions (furosemide) with the combination of LD and hypochlorthiazide if needed. It is highly possible that low systemic arterial pressure marches out in this situation. In this case it is important to force plasma circulation through the kidney with the help of pressor amines introduction instead of further increasing diuretics usage. The non-drug methods for the FRS management (hemodialysis, ultrafiltration and others) could be used also. At this stage a patient cannot be treated in any outpatient department and the current algorithm is beyond the application.
It is obvious that all the possible clinical situations cannot be considered in the presented algorithm. It does not cancel the need in the personal approach to every patient considering the principal disease and comorbidity, living conditions and the attending doctor experience. However it points to the main directions for rational decision search in the management in patients with fluid retention syndrome on an outpatient basis.