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Diuretic Resistant Fluid Overload UF Haemodialysis — ESENeph MCQ

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ModerateChronic Kidney DiseaseDiuretic Resistant Fluid Overload UF HaemodialysisESENeph

A 50-year-old woman with CKD G4 (eGFR 20 mL/min/1.73m2) develops acute pulmonary oedema. She is on maximum-dose furosemide 250 mg BD and metolazone 2.5 mg daily. Despite this, she remains fluid overloaded with peripheral oedema and pulmonary crackles. Urine output is 400 mL/day. What is the next management step for her fluid overload?

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Correct answer: A — Initiate ultrafiltration via haemodialysis

This patient has diuretic-resistant fluid overload in advanced CKD — she is already on high-dose loop diuretic plus thiazide-like agent (sequential nephron blockade). When diuretic resistance persists despite maximal medical therapy in CKD G4-5 with symptomatic fluid overload (pulmonary oedema), urgent ultrafiltration via haemodialysis is indicated. This may be performed as an isolated UF session or as part of initiating renal replacement therapy, depending on the clinical context and whether this episode represents a tipping point towards needing long-term dialysis. Further diuretic dose escalation beyond maximum is futile and risks ototoxicity. Spironolactone adds modest benefit but takes days to act.

Reference: KDIGO 2012 – AKI Guideline; NICE 2021 – NG203 CKD; UKKA 2019 – Dialysis Initiation Guidelines