Effective fluid removal remains one of the toughest challenges in chronic heart failure management. Presented at the European Society of Cardiology (ESC) Congress 2025, the DEA-HF trial explored how kidney function and acid–base balance influence diuretic response in congestion-refractory patients.

The sub-analysis included 42 participants who sequentially received three high-intensity regimens: intravenous (IV) furosemide 250 mg, oral metolazone 5 mg plus IV furosemide 250 mg, and IV acetazolamide 500 mg plus IV furosemide 250 mg. Natriuresis and diuresis were positively correlated with estimated glomerular filtration rate (eGFR), with the highest sodium excretion and urine volume observed in those with eGFR > 45 mL/min/1.73 m². Despite varying kidney function, all eGFR groups achieved comparable improvements in body weight, NT-proBNP, congestion scores, and lung ultrasound B-lines.

Additionally, higher baseline serum bicarbonate levels were associated with greater diuretic efficacy, highlighting a potential metabolic influence on fluid removal. While renal function decline occurred more frequently in patients with eGFR < 30 mL/min/1.73 m², it was not linked to increased hospitalizations. These findings reinforce the importance of kidney function and bicarbonate status in optimizing decongestion strategies for advanced heart failure.