Proposal for New Classification and Practical Use of Diuretics According to Their Effects on the Serum Chloride Concentr
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REVIEW
Proposal for New Classification and Practical Use of Diuretics According to Their Effects on the Serum Chloride Concentration: Rationale Based on the ‘‘Chloride Theory’’ Hajime Kataoka
Received: April 7, 2020 Ó The Author(s) 2020
ABSTRACT Currently, diuretic therapy for heart failure (HF) pathophysiology is primarily focused on the sodium and water balance. Over the last several years, however, chloride (Cl) has been recognized to have an important role in HF pathophysiology, as both a prognostic marker and a possible central factor regulating the body fluid status. I recently proposed a unifying hypothesis for HF pathophysiology, called the ‘‘chloride theory’’, during HF worsening and recovery, as follows. Chloride is the key electrolyte for regulating both reabsorption of tubular electrolytes and water in the kidney through the renin–angiotensin–aldosterone system and distributing body fluid in each compartment of the body. As changes between the serum Cl concentration and plasma volume are intimately associated
Digital features To view digital features for this article go to https://doi.org/10.6084/m9.figshare.12162012. H. Kataoka (&) Internal Medicine, Nishida Hospital, Oita, Japan e-mail: [email protected]
with worsening HF and its recovery after decongestive therapy, modulation of the serum Cl concentration by careful selection and combination of various diuretics and their doses could become an attractive therapeutic option for HF. In this review, I will propose a new classification and practical use of diuretics according to their effects on the serum Cl concentration. Diuretic use according to this classification is expected to be a useful strategy for the treatment of patients with HF.
Keywords: Acetazolamide; Chloride; Diuretics; Heart failure; Loop diuretic; SGLT2 inhibitor; Vasopressin receptor antagonist
Cardiol Ther
Key Summary Points According to the ‘‘chloride theory’’ for heart failure (HF) pathophysiology, modulation of the serum chloride (Cl) concentration by careful selection and combination of various diuretics and their doses could become an attractive therapeutic option for HF This review article initially describes possible physiologic roles and differential effects of Cl in comparison with sodium, the recently developed concept of the ‘‘chloride theory’’, and a diuretic strategy for HF pathophysiology according to this theory Then, new classifications and the appropriate use of diuretics according to their effects on the serum Cl concentration, aiming to achieve an ideal body fluid status and avoid diuretic resistance, will be described Lastly, a practical monitoring method and adjustment of diuretics in patients with HF, with respect to the ‘‘chloride theory’’, will be described to provide suitable Clcentered diuretic strategies Further studies are required to determine the clinical utility of chloride-centered diuretic strategies compared with loop diuretic-centered diuretic strategies by recruiting both a large number and wide spectrum of patients with HF
INTRODUC
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