Diuretic Resistance in Heart Failure: Escalation Ladder

Diuretic resistance in acute heart failure, start to finish- the first inadequate urine output check to the discharge dose. If you're covering a decompensated heart failure patient tonight who isn't responding to IV diuretics, this gets you through the escalation ladder: dose, frequency, infusion, and a second agent, in that order. Built on the Michigan Medicine inpatient diuretic guideline, and the DOSE, ADVOR, 3T, CARRESS-HF, and STRONG-HF trials EDUCATIONAL RESOURCES: The diuretic resistance quick-reference sheet, full study guide, and Anki decks are all available in the channel Etsy page: https://thepreround.etsy.com WHAT'S COVERED: The 2h/8h thresholds that actually define diuretic resistance (over 300 mL at 2h, over 1200 mL at 8h, spot urine Na over 50-70) Why you double the dose instead of adding a fixed increment (the dose-response curve is log-linear) The braking phenomenon and renal venous congestion; why a dose that worked yesterday stops working today Why a rising creatinine in a still-congested patient isn't a reason to hold the diuretic Under-dosing vs. dietary nonadherence vs. true cardiorenal resistance — the mimics table and the two questions that settle it The 4-step escalation ladder: double the dose, increase frequency, start a continuous infusion, then add a second agent Metolazone vs. acetazolamide for sequential nephron blockade, and why ultrafiltration isn't on the ladder 5 ward pearls you can say on rounds tomorrow New case every week. Subscribe if this is useful for the wards. DISCLAIMER Educational content only, not medical advice. I'm a fourth-year medical student (MS4) applying to internal medicine residency, not a licensed physician. This case is de-identified and composite; no real patient information is shown. Content is not a substitute for clinical judgment, institutional protocols, or attending oversight. #ADHF #InternalMedicine #Step2CK diuretic resistance, acute decompensated heart failure, ADHF management, loop diuretic escalation, cardiorenal syndrome, furosemide dosing, internal medicine, IM clerkship, USMLE Step 2 CK, med student, ward pearls, The Preround