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Can saline repletion be the true TARGET for achieving fluid balance in acute heart failure?

Congestion is a complex clinical syndrome defined as signs and symptoms of fluid accumulation that often tracks with increased cardiac filling pressures and circulatory redistributions.1 With loop diuretic therapy being the primary strategy to remove salt and water, comparing strategies of initial dosing and routes of loop diuretics have been the focus of clinical research studies in acute decompensated heart failure (ADHF). Interestingly, only studies comparing diuretic therapy with ultrafiltration have prospectively set volume removal or urine output goals of net negative 3–5 L/day.2 The recently published position paper on the use of diuretics in heart failure with congestion from the Heart Failure Association of the European Society of Cardiology provides some best practice recommendations on how to achieve such goals.3 Based on the assumption that loop diuretics are often effective in relieving congestion by salt and water removal when adequately dosed, choosing an adequate initial and stepwise diuretic dosing needs to pair with assessing diuretic response, potentially with timely assessments of urine output and spot urinary sodium.3 How to best decongest and stabilize ADHF patients remains an ongoing challenge, since persistent congestion confers poorer outcomes.4 With lack of consensus on what constitutes ‘complete decongestion’, there has been suggestions that perhaps either under-dosing or overzealous use of diuretic therapy that surpass the plasma refill rate may contribute to residual congestion at the time of discharge. Indeed, the pathophysiology of diuretic resistance is likely multifactorial and varies over time, including the activation of the renin–angiotensin–aldosterone and sympathetic systems, nephron remodelling, pre-existing renal dysfunction, and importantly, fluid depletion due to slow plasma refilling.5 Therefore, beyond diuretic therapy, stabilization may