Worsening of proteinuria caused by combination therapy of hypertonic saline and low-dose furosemide for treatment of acute decompensated heart failure with overt diabetic nephropathy

A combination of hypertonic saline and furosemide has been proposed as a new therapeutic approach for treating acute decompensated heart failure (ADHF). The advantages of this combination have not only been demonstrated in ADHF but also in refractory ascites due to liver cirrhosis. However, the therapeutic effects of this regimen have never been evaluated in ADHF with overt diabetic nephropathy (ODN). Here, we present an interesting case of a 35-year-old patient admitted to our hospital for ADHF with shortness of breath and systemic edema, complicated with hypertension, type 2 diabetes, and ODN. Echocardiography showed left ventricular enlargement and diffuse hypokinesis, with ejection fraction of 33%. Urinary findings showed total proteinuria of 3597 mg/day during the first day of hospitalization. We initiated decongestion therapy with continuous infusion of hypertonic saline and furosemide. In spite of increased diuresis, edema remained the same and serum albumin decreased from 2.7 g/dl to 2.0 g/dl, and proteinuria increased up to 7344 mg/day. The amount of proteinuria and serum albumin level gradually recovered over time after cessation of the therapy. These data suggest that the combination therapy worsens glomerular hypertension and ODN. Therefore, hypertonic saline and furosemide combination therapy should not be recommended for patients with ODN. Learning objective: Hypertonic saline and low-dose furosemide combination therapy has been proposed as a treatment option for ADHF, especially in refractory congestive heart failure cases. Nevertheless, the efficacy of this treatment in ADHF cases complicated with overt proteinuria is not fully elucidated. This therapy may induce increment of proteinuria in these patients due to aggravation of glomerular hypertension, and may be ineffective for decongestion or to treat edema.