 Given the potential hazards of administering loop diuretics in CHF patients, the remaining options are limited. Changing diuretics strategies from bolus to continuous loop diuretic infusion does not appear to change overall outcomes 21. Alternative strategies for relieving congestion include inhibition of the distal nephron using thiazide diuretics. Thiazide diuretics work synergistically with loop diuretics to induce natriuresis but have an independent association with worsening renal function and death 20,22. Utilizing inotropes to increasing renal perfusion pressure may improve natriuresis, however, it comes with the price of increasing mortality regardless of whether beta-adrenergic agonists dobutamine or phosphodiesterase inhibitors are used 23,24. Ultrafiltration and mechanical unloading of the heart is another therapeutic option, however it was found to be ineffective and associated with worsening renal function 25. Even low doses of dopamine or nesiritide were not effective in improving outcomes in patients with cardiorenal syndrome 26. Higher doses of spironolactone were recently shown to be safe in a prospective cohort treated for acute decompensated heart failure 27. Recently a case report was published showing that patients hospitalized with congestive heart failure, worsening renal function and diuretic resistance were able to be diuresed without adverse effect on renal function or hyperkalemia by treating with escalating doses of spironolactone 28 