Diuretics are an important part of managing the fluid retention in congestive heart failure. In diuretic resistance higher and higher doses of diuretics may produce little if any increase in urine output. Identifying the cause may indicate the appropriate therapeutic response.

Causes of diuretic resistance:

(1) poor compliance with medications

(2) poor compliance with sodium restriction

(3) poor oral absorption of the diuretic (malabsorption, mucosal edema, etc.)

(4) drug interactions that increase metabolism

(5) renal insufficiency

(6) decreased renal perfusion from one or more of the following:

(6a) intravascular volume depletion

(6b) decrease in cardiac output

(6c) reduced glomerular perfusion (associated with ACE inhibitors or other drugs)

(6d) NSAIDS or other drugs affecting prostaglandins

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