Challenges in diuretic therapy: A case-based discussion

Diuretics are amongst the most prescribed medications in both the inpatient and outpatient settings. They are used extensively in diverse disease states including heart failure, acute and chronic kidney disease, cirrhosis, and diseases of excess capillary permeability such as sepsis, malignancy, and malnutrition. All are characterized by total body sodium overabundance which commonly manifests as edema. The use of diuretics is however not bereft of complications. These complications frequently limit the correction of hypervolemia, resulting in continued patient suffering and frustration for the clinician. In this review, we employ a case-based approach to discuss three common challenges encountered during diuretic therapy: diuretic resistance that characterizes the nephrotic syndrome, diuretic-induced metabolic alkalosis, and diuretic-associated hyponatremia. We empower the clinician to effectively meet these challenges by providing a mechanistic understanding of these complications and their solutions.