Renal tubular resistance is the primary driver for loop diuretic resistance in acute heart failure

Background Loop diuretic resistance is a common barrier to effective decongestion in acute heart failure (AHF), and is associated with poor outcome. Specific mechanisms underlying diuretic resistance are currently unknown in contemporary AHF patients. We therefore aimed to determine the relative importance of defects in diuretic delivery vs. renal tubular response in determining diuretic response (DR) in AHF. Methods and results Fifty AHF patients treated with intravenous bumetanide underwent a 6‐h timed urine collection for sodium and bumetanide clearance. Whole‐kidney DR was defined as sodium excreted per doubling of administered loop diuretic and represents the sum of defects in drug delivery and renal tubular response. Tubular DR, defined as sodium excreted per doubling of renally cleared (urinary) loop diuretic, captures resistance specifically in the renal tubule. Median administered bumetanide dose was 3.0 (2.0–4.0) mg with 52 (33–77)% of the drug excreted into the urine. Significant between‐patient variability was present as the administered dose only explained 39% of variability in the quantity of bumetanide in urine. Cumulatively, factors related to drug delivery such as renal bumetanide clearance, administered dose, and urea clearance explained 28% of the variance in whole‐kidney DR. However, resistance at the level of the renal tubule (tubular DR) explained 71% of the variability in whole‐kidney DR. Conclusion Defects at the level of the renal tubule are substantially more important than reduced diuretic delivery in determining diuretic resistance in patients with AHF.