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Kidney Week

Abstract: PO0235

Diuretic Resistance: When to Consider Hydralazine?

Session Information

  • AKI Mechanisms - 3
    October 22, 2020 | Location: On-Demand
    Abstract Time: 10:00 AM - 12:00 PM

Category: Trainee Case Report

  • 103 AKI: Mechanisms


  • Alshehri, Mohammed, MedStar Georgetown University Hospital, Washington, District of Columbia, United States
  • Jabaji, Ramez S., MedStar Georgetown University Hospital, Washington, District of Columbia, United States
  • Wilcox, Christopher S., MedStar Georgetown University Hospital, Washington, District of Columbia, United States

We present a case of acute cardiorenal syndrome complicating heart failure with preserved ejection fraction (HFpEF) leading to severe diuretic resistant fluid retention that was alleviated by coincident hydralazine therapy.

Case Description

A 52-Year-old woman with a history of obesity, hypertension, congestive heart failure with HFpEF (EF60-65%), and alcoholic liver disease presented with a 3-day history of mental status change. Her serum creatinine was 3.6mg/dL, compared to 0.8mg/dL a month prior. She was volume overloaded with distended jugular veins, pulmonary crackles, and +2 edema to her lower abdomen; she had a 30Kg weight gain over 5 months . Her urine sodium and chloride were <10mmol/L. Urine analysis had a SG of 1.017 without proteinuria. Diuretic therapy was initiated with IV furosemide 80 mg twice daily and was escalated progressively to IV furosemide 20 mg/h with IV chlorothiazide 500 mg twice daily. However, these large doses of intravenous diuretics failed to increase daily urine output above 1000 ml. After 20 hours of stable diuretics, vasodilator therapy was initiated with low dose hydralazine 10 mg thrice daily. Within one day, her urine output more than doubled and, over the next 3 days of the stable therapy, it peaked at 4 liters. Her fraction Na excretion (FENa) was initially 0.1%; it increased to a maximum of 1.9% with the high IV continuous diuretic therapy but increased further to 3.8%-6.2% over 9 days after hydralazine was added to the diuretic regimen. After addition of hydralazine, her congestion dissipated, she lost 23 Kg and the diuretic regimen was reduced eventually to furosemide 80 mg BID and spironolactone 200 mg daily prior to her discharge with a serum creatinine of 1.3 mg/dl. At follow up after 3 months, her symptoms remained well controlled, her weight was reduced by a further 10 kg and her serum creatinine was 0.9 mg/dl.


Hydralazine has been recommended to treat diuretic resistance in HF by increasing cardiac output, renal blood flow and renal diuretic delivery. However, our case suggests that hydralazine greatly improves renal tubular diuretic responsiveness as her FENa increased 3 fold. This is not likely due to better renal diuretic delivery since the patient received constant IV infusions of two diuretics at doses well above their ceiling. Further clinical trials and mechanistic studies of hydralazine-diuretic interaction are warranted.