The Paradox of Hypertonic Saline Infusion for Patients with Heart Failure

Fluid/sodium overload is the primary reason for hospital admission for patients with acute decompensated heart failure. Unfortunately, congestion often remains undertreated and is associated with significant adverse outcomes in patients with congestive heart failure (CHF). Potent loop diuretics have long been accepted as the first-line treatment for these patients. However, recurrent hospital admission, due in part to a lack of response to diuretics, becomes common as heart failure progresses.

While the goal of acute decompensated heart failure (ADHF) therapy has historically been to correct the excess of sodium chloride and water in the body, recent studies in patients with diuretic-resistant CHF have reported a paradoxical role for repletion with hypertonic saline (HS) infusion during continued use of loop diuretics to enhance diuresis. With the increasing use of combined therapy in the intensive care unit and recent trials of combined therapy in ambulatory patients, nephrologists are increasingly involved in its use.

Several clinical trials in ADHF have demonstrated a role for HS in the improvement of outcomes such as decongestion, diuresis, kidney function, weight loss, mortality, length of stay, and readmission rates. This is a review for nephrologists of the potential effects of infusion of HS in combination with loop diuretics in patients with ADHF.