Chinese expert consensus for the diagnosis and management of diuretic resistance in patients with heart failure
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摘要: 利尿剂是住院心力衰竭(heart failure，HF)特别是急性失代偿心力衰竭(acute decompensated heart failure，ADHF)患者容量管理的基石。利尿剂抵抗(diuretic resistance，DR)表现为对利尿剂的反应减低甚至完全失效，不仅导致住院时间延长，还使病死率和再住院率增加。目前国内外尚缺乏对HF患者DR诊断和管理的共识。本共识梳理DR的定义、机制、诊断和管理等方面内容，并基于临床研究结果和专家经验，提出相应的处理建议，旨在提高临床医师对DR的认识，并规范DR治疗。Abstract: Diuretics play a crucial role in volume management for hospitalized patients with heart failure (HF), particularly those with acute decompensated HF (ADHF). Diuretic resistance (DR), manifested as a diminished response or even a failure to diuretics, which not only prolongs in-hospital stay but also increases mortality and rehospitalization. There is not yet a consensus regarding the diagnosis and management of DR in heart failure patients. Therefore, this consensus focuses on elucidating the definition, mechanisms, diagnosis, and management of DR. Based on clinical research findings and expert experiences, it offers recommendations for treatment, aiming to enhance physicians' awareness and standardize the management.
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Key words:
- heart failure /
- diuretic resistance /
- volume management
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药物 起始剂量 每日最大剂量 常用剂量 襻利尿剂 呋塞米 20~40 mg，1次/d
20~40 mg，1~2次/d(AHA指南)120~160 mg
600 mg(AHA指南)20~80 mg
40~240 mg(ESC指南)托拉塞米 10 mg，1次/d
5~10 mg，1次/d(ESC指南)
10~20 mg，1次/d(AHA指南)100 mg
200 mg(AHA指南)10~40 mg
10~20 mg(ESC指南)布美他尼 0.5~1 mg，1次/d
0.5~1 mg，1~2次/d(AHA指南)6~8 mg
10 mg(AHA指南)1~4 mg
1~5 mg(ESC指南)噻嗪类利尿剂 氢氯噻嗪 12.5~25 mg，1~2次/d
25 mg，1次/d(ESC指南)
25 mg，1~2次/d(AHA指南)100 mg
200 mg(AHA指南)25~50 mg
12.5~100 mg(ESC指南)吲达帕胺 2.5 mg，1次/d 5 mg 2.5~5 mg 美托拉宗 2.5 mg，1次/d 20 mg 2.5~10 mg 醛固酮受体拮抗剂 螺内酯 10~20 mg，1次/d
25 mg，1次/d(ESC指南)20~40 mg
50 mg(ESC指南)依普利酮 25 mg，1次/d 50 mg 保钾利尿剂 阿米洛利 2.5 mga/5 mgb，1次/d 20 mg 5~10 mga/10~20 mgb 氨苯蝶啶 25 mga/50 mgb，1次/d 200 mg 100 mga/200 mgb 血管升压素V2受体拮抗剂 托伐普坦 7.5~15 mg，1次/d 30 mg 15 mg 碳酸酐酶抑制剂 乙酰唑胺 500 mg，1次/d，3 d 注：a与血管紧张素转换酶抑制剂(ACEI)或血管紧张素Ⅱ受体阻滞剂(ARB)合用时的剂量；b不与ACEI或ARB合用时的剂量。 
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