General principles of the treatment of edema in adults
- Richard H Sterns, MD
Richard H Sterns, MD
- Editor-in-Chief — Nephrology
- Section Editor — Fluid and Electrolytes
- Professor Emeritus
- University of Rochester School of Medicine and Dentistry
Edema is defined as a palpable swelling produced by expansion of the interstitial fluid volume; when massive and generalized, the excess fluid accumulation is called anasarca. A variety of clinical conditions are associated with the development of edema, including heart failure, cirrhosis, and the nephrotic syndrome, as well as local conditions such as venous and lymphatic disease or malignant ascites (table 1). (See "Pathophysiology and etiology of edema in adults".)
The general principles for the treatment of edema in adults, including the use of diuretics to remove the excess fluid, will be reviewed here. The specific effects of diuretics in the three major generalized edema states (heart failure, cirrhosis, and the nephrotic syndrome), the clinical features and diagnosis of the generalized edematous states, and the treatment of refractory edema are discussed separately. (See "Use of diuretics in patients with heart failure" and "Ascites in adults with cirrhosis: Initial therapy", section on 'Diuretic therapy' and "Pathophysiology and treatment of edema in patients with the nephrotic syndrome" and "Clinical manifestations and diagnosis of edema in adults" and "Treatment of refractory edema in adults".)
GENERAL PRINCIPLES OF THERAPY
Treatment of edema consists of reversal of the underlying disorder (if possible), dietary sodium restriction (to minimize fluid retention), and, in most patients, diuretic therapy. Before initiating diuretic therapy, it is important to consider the following questions, which apply to all edematous states:
●When must edema be treated?
●What are the consequences of the removal of edema fluid?
- Cohn JN. Blood pressure and cardiac performance. Am J Med 1973; 55:351.
- Stampfer M, Epstein SE, Beiser GD, Braunwald E. Hemodynamic effects of diuresis at rest and during intense upright exercise in patients with impaired cardiac function. Circulation 1968; 37:900.
- Lal S, Murtagh JG, Pollock AM, et al. Acute haemodynamic effects of frusemide in patients with normal and raised left atrial pressures. Br Heart J 1969; 31:711.
- Pockros PJ, Reynolds TB. Rapid diuresis in patients with ascites from chronic liver disease: the importance of peripheral edema. Gastroenterology 1986; 90:1827.
- Shear L, Ching S, Gabuzda GJ. Compartmentalization of ascites and edema in patients with hepatic cirrhosis. N Engl J Med 1970; 282:1391.
- BARTTER FC, DUNCAN LE Jr, LIDDLE GW. The effect of changes in body sodium on extracellular fluid volume and aldosterone and sodium excretion by normal and edematous men. J Clin Invest 1956; 35:1299.
- Arroyo V, Bosch J, Gaya-Beltrán J, et al. Plasma renin activity and urinary sodium excretion as prognostic indicators in nonazotemic cirrhosis with ascites. Ann Intern Med 1981; 94:198.
- Boyer TD. Removal of ascites: what's the rush? Gastroenterology 1986; 90:2022.
- Pockros PJ, Esrason KT, Nguyen C, et al. Mobilization of malignant ascites with diuretics is dependent on ascitic fluid characteristics. Gastroenterology 1992; 103:1302.
- Strom BL, Schinnar R, Apter AJ, et al. Absence of cross-reactivity between sulfonamide antibiotics and sulfonamide nonantibiotics. N Engl J Med 2003; 349:1628.
- Brater DC, Voelker JR. Use of diuretics in patients with renal disease. In: Pharmacotherapy of Renal Disease and Hypertension (Contemporary Issues in Nephrology), Bennett WM, McCarron DA (Eds), Churchill Livingstone, New York 1987. Vol 17.
- Rudy DW, Voelker JR, Greene PK, et al. Loop diuretics for chronic renal insufficiency: a continuous infusion is more efficacious than bolus therapy. Ann Intern Med 1991; 115:360.
- Rose BD. Chapter16. In: Clinical Physiology of Acid-Base and Electrolyte Disorders, 5th ed, McGraw-Hill, New York 2001.
- Bock HA, Stein JH. Diuretics and the control of extracellular fluid volume: role of counterregulation. Semin Nephrol 1988; 8:264.
- Ikram H, Chan W, Espiner EA, Nicholls MG. Haemodynamic and hormone responses to acute and chronic frusemide therapy in congestive heart failure. Clin Sci (Lond) 1980; 59:443.
- GENERAL PRINCIPLES OF THERAPY
- When must edema be treated?
- What are the consequences of the removal of edema fluid?
- How rapidly should edema fluid be removed?
- Venous insufficiency, lymphedema, and malignant ascites
- USE OF DIURETICS
- Choice of loop diuretic
- Diuretic dose
- Time course of diuretic response
- Refractory edema
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