J Clin Med Res

Journal of Clinical Medicine Research, ISSN 1918-3003 print, 1918-3011 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Clin Med Res and Elmer Press Inc

Journal website https://jocmr.elmerjournals.com

Original Article

Volume 18, Number 4, April 2026, pages 271-281

Factors Predicting Diuretic Resistance in Patients With Acute Decompensated Heart Failure

↓ Figure 2. AUC result for the proposed diuretic resistance scoring system. AUC: area under the curve.

↓ **Table 1.** Baseline Characteristics of Study Subjects
Variables	All (N = 535)	Patients with diuretic resistance (N = 365 (68.2%))	Patients without diuretic resistance (N = 170 (31.8%))	P-value
BUN: blood urea nitrogen; DM: diabetes mellitus; CAD: coronary artery disease; CKD: chronic kidney disease; DBP: diastolic blood pressure; GFR: glomerular filtration rate; IV: intravenous; LVEF: left ventricular ejection fraction; max: maximum; min: minimum; SD: standard deviation; TAPSE: tricuspud annular point of systolic excursion.
Age (years), median (min–max)	58 (18–91)	58 (18–81)	61 (20–91)	0.011
Gender
Male, n (%)	425 (79.4%)	290 (79.5%)	135 (79.4%)	0.991
Female, n (%)	110 (20.6%)	75 (20.5%)	35 (20.6%)
DM, n (%)	252 (47.1%)	191 (52.3%)	61 (35.9%)	< 0.001
CAD, n (%)	428 (80%)	289 (79.2%)	139 (81.8%)	0.486
CKD, n (%)	37 (6.9%)	31 (8.5%)	6 (3.5%)	0.035
Usage of IV loop diuretics > 6 days	216 ( 40.4%)	175 (47.9%)	41 (24.1%)	< 0.001
Oral loop diuretic dose > 80 mg/day, n (%)	44 (8.2%)	43 (11.8%)	1 (0.6%)	< 0.001
Clinical parameters
SBP (mm Hg), median (min–max)	125 ± 24	122 ± 23	130 ± 25	< 0.001
DBP (mm Hg), median (min–max)	76 ± 15	75 ± 14	79 ± 16	0.006
LVEF (%), median (min–max)	25 (13–79)	23 (13–79)	29 (14–77)	< 0.001
TAPSE (mm), median (min–max)	16 (5–30)	15 (5–30)	17 (5–28)	0.019
Laboratory values
Serum creatinine (mg/dL), mean (SD)	1.46 ± 0.63	1.54 ± 0.65	1.28 ± 0.57	< 0.001
GFR (mL/min/1.73 m²), median (min–max)	53 (16–146)	50 (16–132)	67 (17–146)	< 0.001
BUN (mg/dL), mean (SD)	25 ± 14	27 ± 14	20 ± 12	< 0.001
Serum sodium (mmol/L), median (min–max)	137 (111–150)	136 (111–144)	138 (118–150)	< 0.001
Serum potassium (mmol/L), mean (SD)	4.0 ± 0.69	4.1 ± 0.7	4.0 ± 0.6	0.192
Serum chloride (mmol/L), median (min–max)	100 (78–111)	98 (78–110)	102 (82–111)	< 0.001

↓ Table 1. Baseline Characteristics of Study Subjects

Variables

All (N = 535)

Patients with diuretic resistance (N = 365 (68.2%))

Patients without diuretic resistance (N = 170 (31.8%))

P-value

BUN: blood urea nitrogen; DM: diabetes mellitus; CAD: coronary artery disease; CKD: chronic kidney disease; DBP: diastolic blood pressure; GFR: glomerular filtration rate; IV: intravenous; LVEF: left ventricular ejection fraction; max: maximum; min: minimum; SD: standard deviation; TAPSE: tricuspud annular point of systolic excursion.

Age (years), median (min–max)

58 (18–91)

58 (18–81)

61 (20–91)

0.011

Gender

Male, n (%)

425 (79.4%)

290 (79.5%)

135 (79.4%)

0.991

Female, n (%)

110 (20.6%)

75 (20.5%)

35 (20.6%)

DM, n (%)

252 (47.1%)

191 (52.3%)

61 (35.9%)

< 0.001

CAD, n (%)

428 (80%)

289 (79.2%)

139 (81.8%)

0.486

CKD, n (%)

37 (6.9%)

31 (8.5%)

6 (3.5%)

0.035

Usage of IV loop diuretics > 6 days

216 ( 40.4%)

175 (47.9%)

41 (24.1%)

< 0.001

Oral loop diuretic dose > 80 mg/day, n (%)

44 (8.2%)

43 (11.8%)

1 (0.6%)

< 0.001

Clinical parameters

SBP (mm Hg), median (min–max)

125 ± 24

122 ± 23

130 ± 25

< 0.001

DBP (mm Hg), median (min–max)

76 ± 15

75 ± 14

79 ± 16

0.006

LVEF (%), median (min–max)

25 (13–79)

23 (13–79)

29 (14–77)

< 0.001

TAPSE (mm), median (min–max)

16 (5–30)

15 (5–30)

17 (5–28)

0.019

Laboratory values

Serum creatinine (mg/dL), mean (SD)

1.46 ± 0.63

1.54 ± 0.65

1.28 ± 0.57

< 0.001

GFR (mL/min/1.73 m²), median (min–max)

53 (16–146)

50 (16–132)

67 (17–146)

< 0.001

BUN (mg/dL), mean (SD)

25 ± 14

27 ± 14

20 ± 12

< 0.001

Serum sodium (mmol/L), median (min–max)

137 (111–150)

136 (111–144)

138 (118–150)

< 0.001

Serum potassium (mmol/L), mean (SD)

4.0 ± 0.69

4.1 ± 0.7

4.0 ± 0.6

0.192

Serum chloride (mmol/L), median (min–max)

100 (78–111)

98 (78–110)

102 (82–111)

< 0.001

↓ **Table 2.** Bivariate Analysis Result
Variable	Diuretic resistance	P	OR	95% CI
BUN: blood urea nitrogen; CAD: coronary artery disease; CI: confidence interval; CKD: chronic kidney disease; DBP: diastolic blood pressure; DM: diabetes mellitus; GFR: glomerular filtration rate; LVEF: left ventricular ejection fraction; TAPSE: tricuspud annular point of systolic excursion.
Age
> 58 years	194	72.4	74	27.6	0.041	0.679	0.471	0.980
≤ 58 years	171	64	96	36
Gender
Male	290	68.3	135	31.7	1.000	1.002	0.639	1.572
Female	75	67.9	35	32.1
DM
Yes	191	75.8	61	24.2	< 0.001	1.961	1.348	2.853
No	174	61.5	109	38.5
CAD
Yes	289	67.5	139	32.5	0.562	0.848	0.533	1.349
No	76	71	31	29
CKD
Yes	31	83.8	6	16.2	0.043	2.537	1.038	6.202
No	334	67	164	33
History of IV loop diuretic use > 6 days
Yes	175	81	41	19	< 0.001	2.898	1.929	4.354
No	190	59.6	129	40.4
Oral loop diuretic dose > 80 mg/day
Yes	43	97.7	1	2.3	< 0.001	22.568	3.081	165.322
No	169	34.4	322	65.6
SBP
< 90 mm Hg	18	75	6	25	0.654	1.418	0.553	3.639
≥ 90 mm Hg	347	68	164	32
DBP
< 60 mm Hg	42	65.6	22	34.4	0.668	0.875	0.504	2.998
≥ 60 mm Hg	323	68.6	148	31.4
LVEF
≤ 49%	348	70.2	148	29.8	0.001	3.016	1.581	5.756
≥ 50%	18	43.9	23	56.1
TAPSE
< 17 mm	209	72.1	81	27.9	0.041	1.472	1.021	2.122
≥ 17 mm	156	63.7	89	36.3
Serum creatinine
≥ 1.5 mg/dL	210	62.7	125	37.3	< 0.001	2.050	1.376	3.055
< 1.5 mg/dL	155	77.5	45	22.5
GFR
≤ 59 mL/min/1.73 m²	233	75	78	25	< 0.001	2.082	1.439	3.013
≥ 60 mL/min/1.73 m²	132	59	92	41
BUN
≥ 21 mg/dL	227	80	57	20	< 0.001	3.261	2.225	4.779
< 21 mg/dL	138	55	113	45
Serum sodium
< 135 mmol/L	122	78.2	34	21.8	0.002	2.008	1.301	3.100
≥ 135 mmol/L	243	64	136	36
Serum potassium
< 3.5 mmol/L	68	66	35	34	0.638	0.883	0.560	1.393
≥ 3.5 mmol/L	297	68.8	135	31.2
Serum chloride
< 98 mmol/L	158	83.6	31	16.4	< 0.001	3.422	2.202	5.319
≥ 98 mmol/L	207	59.8	139	40.2

↓ Table 2. Bivariate Analysis Result

Variable

Diuretic resistance

95% CI

Yes

Minimum

Maximum

BUN: blood urea nitrogen; CAD: coronary artery disease; CI: confidence interval; CKD: chronic kidney disease; DBP: diastolic blood pressure; DM: diabetes mellitus; GFR: glomerular filtration rate; LVEF: left ventricular ejection fraction; TAPSE: tricuspud annular point of systolic excursion.

Age

> 58 years

194

72.4

27.6

0.041

0.679

0.471

0.980

≤ 58 years

171

Gender

Male

290

68.3

135

31.7

1.000

1.002

0.639

1.572

Female

67.9

32.1

Yes

191

75.8

24.2

< 0.001

1.961

1.348

2.853

174

61.5

109

38.5

CAD

Yes

289

67.5

139

32.5

0.562

0.848

0.533

1.349

CKD

Yes

83.8

16.2

0.043

2.537

1.038

6.202

334

164

History of IV loop diuretic use > 6 days

Yes

175

< 0.001

2.898

1.929

4.354

190

59.6

129

40.4

Oral loop diuretic dose > 80 mg/day

Yes

97.7

2.3

< 0.001

22.568

3.081

165.322

169

34.4

322

65.6

SBP

< 90 mm Hg

0.654

1.418

0.553

3.639

≥ 90 mm Hg

347

164

DBP

< 60 mm Hg

65.6

34.4

0.668

0.875

0.504

2.998

≥ 60 mm Hg

323

68.6

148

31.4

LVEF

≤ 49%

348

70.2

148

29.8

0.001

3.016

1.581

5.756

≥ 50%

43.9

56.1

TAPSE

< 17 mm

209

72.1

27.9

0.041

1.472

1.021

2.122

≥ 17 mm

156

63.7

36.3

Serum creatinine

≥ 1.5 mg/dL

210

62.7

125

37.3

< 0.001

2.050

1.376

3.055

< 1.5 mg/dL

155

77.5

22.5

GFR

≤ 59 mL/min/1.73 m²

233

< 0.001

2.082

1.439

3.013

≥ 60 mL/min/1.73 m²

132

BUN

≥ 21 mg/dL

227

< 0.001

3.261

2.225

4.779

< 21 mg/dL

138

113

Serum sodium

< 135 mmol/L

122

78.2

21.8

0.002

2.008

1.301

3.100

≥ 135 mmol/L

243

136

Serum potassium

< 3.5 mmol/L

0.638

0.883

0.560

1.393

≥ 3.5 mmol/L

297

68.8

135

31.2

Serum chloride

< 98 mmol/L

158

83.6

16.4

< 0.001

3.422

2.202

5.319

≥ 98 mmol/L

207

59.8

139

40.2

↓ **Table 3.** Final Model of Multivariate Analysis
Variable	B	P value	Exp(B)	95% CI
B: coefficient B; BUN: blood urea nitrogen; CI: confidence interval; LVEF: left ventricular ejection fraction; SE: standard error.
Diabetes mellitus	0.528	0.013	1.696	1.120	2.570
History of IV loop diuretic use > 6 days	0.713	0.002	2.039	1.306	3.184
Daily loop diuretic dosage > 80 mg	2.839	0.006	17.107	2.265	129.177
LVEF ≤ 49%	1.159	0.002	3.186	1.530	6.633
BUN ≥ 21 mg/dL	0.907	< 0.001	2.477	1.641	3.740
Serum chloride < 98 mmol/L	0.993	< 0.001	2.699	1.672	4.357

↓ Table 3. Final Model of Multivariate Analysis

Variable

P value

Exp(B)

95% CI

Minimum

Maximum

B: coefficient B; BUN: blood urea nitrogen; CI: confidence interval; LVEF: left ventricular ejection fraction; SE: standard error.

Diabetes mellitus

0.528

0.013

1.696

1.120

2.570

History of IV loop diuretic use > 6 days

0.713

0.002

2.039

1.306

3.184

Daily loop diuretic dosage > 80 mg

2.839

0.006

17.107

2.265

129.177

LVEF ≤ 49%

1.159

0.002

3.186

1.530

6.633

BUN ≥ 21 mg/dL

0.907

< 0.001

2.477

1.641

3.740

Serum chloride < 98 mmol/L

0.993

< 0.001

2.699

1.672

4.357

↓ **Table 4.** Scoring System Weighing
Variable	B	SE	B/SE	(B/SE)/2.491
B: coefficient B; BUN: blood urea nitrogen; LVEF: left ventricular ejection fraction; SE: standard error.
Diabetes mellitus	0.528	0.212	2.491	1.0
History of IV loop diuretic use > 6 days	0.713	0.227	3.141	1.3
Daily loop diuretic dosage > 80 mg	2.839	1.032	2.751	1.1
LVEF ≤ 49%	1.159	0.374	3.099	1.2
BUN ≥ 21 mg/dL	0.907	0.210	4.319	1.7
Serum chloride < 98 mmol/L	0.993	0.244	4.070	1.6

↓ Table 4. Scoring System Weighing

Variable

B/SE

(B/SE)/2.491

B: coefficient B; BUN: blood urea nitrogen; LVEF: left ventricular ejection fraction; SE: standard error.

Diabetes mellitus

0.528

0.212

2.491

1.0

History of IV loop diuretic use > 6 days

0.713

0.227

3.141

1.3

Daily loop diuretic dosage > 80 mg

2.839

1.032

2.751

1.1

LVEF ≤ 49%

1.159

0.374

3.099

1.2

BUN ≥ 21 mg/dL

0.907

0.210

4.319

1.7

Serum chloride < 98 mmol/L

0.993

0.244

4.070

1.6

↓ **Table 5.** Final Proposed Score Model
Variable	Score
BUN: blood urea nitrogen; LVEF: left ventricular ejection fraction.
Diabetes mellitus	1
History of IV loop diuretic use > 6 days	1
Daily loop diuretic dosage > 80 mg	1
LVEF ≤ 49%	1
BUN ≥ 21 mg/dL	2
Serum chloride < 98 mmol/L	2
Total score	8

↓ Table 5. Final Proposed Score Model

Variable

Score

BUN: blood urea nitrogen; LVEF: left ventricular ejection fraction.

Diabetes mellitus

History of IV loop diuretic use > 6 days

Daily loop diuretic dosage > 80 mg

LVEF ≤ 49%

BUN ≥ 21 mg/dL

Serum chloride < 98 mmol/L

Total score

↓ **Table 6.** Scoring System Interpretation
Score	Criteria	Probability of diuretic resistance
1–3	Low risk	39–65%
4–6	Moderate risk	76–91%
7–8	High risk	95–96.4%

↓ Table 6. Scoring System Interpretation

Score

Criteria

Probability of diuretic resistance

1–3

Low risk

39–65%

4–6

Moderate risk

76–91%

7–8

High risk

95–96.4%