Diuretic combinations in the treatment of edema: Rationale and recommendations

Most patients with edematous disorders such as congestive heart failure, nephrotic syndrome, and cirrhotic ascites can be treated successfully with dietary NaCl restrictum and a single class of diuretic drug. For resistant patients, it may be necessary to combine two different classes of diuretic drug to control symptoms. Recent experimental work has shown that specific renal adaptations contribute to diuretic resistance by increasing the capacity of the kidney to reabsorb NaCl. Combination diuretic therapy can be used to overcome these processes, but its indiscriminate use can also lead to serious complications. A rational approach to diuretic-resistant patients is based on understanding how adaptive renal responses can be heated and prevented using targeted diuretic therapy. Such an approach provides the most effective diuresis without undue complications.