Question

A 41-year-old obese male patient is diagnosed with congestive heart failure (CHF). He is told to begin a moderate exercise routine with a healthy diet and is prescribed several medications — including a diuretic.

1. Based on your knowledge of the kidney and the disease of CHF, what factors would be important in selecting a specific diuretic? How would you explain to this patient how it works?
2. If this patient developed a disease that caused the renal blood flow to be diminished, how might this impact the medication he is taking for his congestive heart failure? As his health care provider, how would you change his treatment in this situation?

Answer 1

Heart failure can occur if the heart cannot pump (systolic) or fill (diastolic) adequately.diuretic play a major role in the management of heartfailure.

The main operational objective of diuretic therapy in patients who present congestive heart failure and hypertension is to reduce or to suppress excess bodily fluid. Effective diuretic therapy decreases cardiac size when the heart is dilated, and it reduces lung congestion and excess water. Consequently, external respiratory work diminishes and cardiac output would be redistributed in favour of systemic vascular beds other than that of the respiratory muscles; dyspnoea decreases markedly and there is a slight reduction in fatigue. This clinical improvement and the fall in body weight caused by diuretics entail an increase in effort capacity.

Loop and/or thiazide-type diuretics may be used to augment natriuresis in patients with congestive heart failure and hypertension. The state of renal function, the existence of certain co-morbid conditions, potential untoward drug actions, and possible interactions of diuretics with nutrients and with other drugs are some of the factors that must be considered at the time of deciding on the diuretic drugs and doses to be prescribed. Spironolactone has been found to increase life expectancy and to reduce hospitalisation frequency when added to the conventional therapeutic regimen of patients with advanced congestive heart failure and systolic dysfunction. Therefore, spironolactone should be the drug of choice to oppose the kaliuretic effect of a loop or of a thiazide-type diuretic.

The main action in heart failure is, patient had repeated episode of pulmonary edema, there by increase fluids in the lungs and edema in the periphery. And also have high bp for these patients. Diuretics removes excess fluid from the body and cause hypovolemia, there by the patient lung symptoms such as dyspnoea will reduce, and hypertension also can control with these diuretics. And the heart size also reduce in case of hypertrophic cardiomyopathy.

Heart failure treatments can affect renal function in a variety of ways, with decreased glomerular filtration rate (GFR) during treatment often denoting a poorer prognosis.Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) reduce GFR through intrarenal mechanisms.Diuretics may predispose to prerenal azotemia through intravascular volume depletion, excessive cardiac preload reduction, and a resulting reduction in cardiac output. Loop diuretics also induce intrarenal mechanisms for reducing GFR, principally through adenosine release and diminished glomerular blood flow and filtration pressure, through A1-receptor stimulation.these drugs increase the serum creatinine level.

For both kidney dysfunction and heart dysfunction these drugs play a major role. Combined heart and kidney disease is usually treated with several drugs. Control of high blood pressure is key.These drugs all benefit patients with heart failure as they counteract the over-activation of the hormone system. However, they can have a negative effect on the kidneys so it takes careful monitoring and frequent blood tests to get the balance right.if we are not keeping these drugs also cause seriou health problems. So initially we can reduce the dose and observe the kidney function. If it is not worsening the kidney function we can continue with that. If necessary we should go for a dialysis for saving kidney. This risk can be reduce by following measures

Be a non-smoker.
Eat a low-salt diet.
Ask your doctor or nurse how to adjust drug dosage according to your blood test results and weight. Weigh yourself regularly at home to warn of fluid overload or dehydration.
Get to know your drugs ask your doctor, specialist nurse or pharmacist to explain.
Exercise regularly swimming, cycling, dancing or power walking all help to lower blood pressure and improve heart and muscle function.

Maintain a balance treatment is necessary to keep both heart and kidney healthy.