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Decongestion and diuretic assistant

A guided diuretic day built on the ESC 2026 decongestion section and the KDIGO 2026 diuretic framework, shown side by side. It reports what each source says for the values entered; it does not write an order.

Setting
Framework
eGFR 84K 4.3SBP 120congestion: euvolaemic

The same values as in the patient editor in the header and on the other pages: change one here and it changes there.

Sex

Calculated 84 (CKD-EPI 2021)

Kidney stage: G2 (eGFR 60–89).

Loop diuretic taken before this episode
Agent

Saved on the patient, so Plan and Uptitrate see it too.

ESC 2026, section 7.5.4 and Table S7

Worsening chronic HF outside hospital: i.v. diuretic sessions (3–6 h infusions dosed from the oral regimen, day hospital or hospital-at-home) or oral intensification: start a loop diuretic, raise the total daily dose, or temporarily add an agent with a different mechanism.

  1. Add i.v. acetazolamide 500 mg once daily

    ESC 2026

    Short-term i.v. acetazolamide should be considered in patients with fluid overload previously treated with loop diuretics (Class IIa, B1; ADVOR). It may be preferable in more advanced CKD and is the agent of choice with metabolic alkalosis.

  2. Add oral hydrochlorothiazide dosed by eGFR

    Hydrochlorothiazide 25 mg daily at eGFR 84.
    ESC 2026

    25 mg (eGFR >50), 50 mg (eGFR 20–50) or 100 mg daily (eGFR <20) (Class IIa, B1; CLOROTIC). CLOROTIC showed more weight loss but also more worsening kidney function and hypokalaemia.

  3. Oral metolazone 2.5–5 mg (advanced HF, diuretic resistance or eGFR <30)

    ESC 2026

    In advanced HF with diuretic resistance, as part of sequential nephron blockade, or with eGFR <30, with careful monitoring of eGFR and electrolytes.

Checklist for diuretic resistance (Table S7)

Practical checklist for an insufficient response in chronic HF (Table S7): salt and fluid intake, dose, switching to bumetanide or torsemide, adding or increasing an MRA, combining with a thiazide or metolazone, dosing twice daily or on an empty stomach, a short i.v. course, ultrafiltration.

Potassium and creatinine come from the patient; enter today's values below if they changed.
Baseline creatinine
1

Nothing to flag for these values. The sources' monitoring statements:

Monitoring

Serial safety indicators: blood pressure, heart rate, creatinine, potassium, NT-proBNP; in chronic HF, re-check chemistry 1–2 weeks after a dose increase.

When to start or resume foundational therapy

ESC 2026

Start or optimize foundational therapy in parallel with decongestion: SGLT2 inhibitors are recommended in hospital after initial stabilization (Class I, B1), starting MRA, SGLT2i or ARNI in this phase is feasible and safe, and FMT already on board is continued unless there is hypoperfusion. A more conservative approach may be reserved for high-risk groups (low eGFR, hypotension, hyperkalaemia history).

See this patient's FMT plan