 Diuretic therapy is the most common means to relieve congestion in acute decompensated heart failure ADHF and approximately 90 of patients are treated with loop diuretics 7. Although loop diuretics are a cornerstone ADHF care and carries the highest level of recommendation by the American Heart Association Class I; the guideline is supported by the lowest level of evidence Class C 8. While effective at natriuresis, loop diuretics are known to stimulate the SNS and RAAS, both of which have adverse consequence in heart failure 9,10. Not only is the RAAS system stimulated due to changes in arterial filling, furosemide blocks sodium chloride transport at the macula densa causing renin release independent of renal sodium loss 11. With increase stimulation of renin release, vasoconstriction of the renal artery ensues causing or further exacerbating renal insufficiency 12. Long-term utilization of loop diuretics results in hypertrophy of the distal nephron and increased expression of a sodium chloride co-transporter 13. These changes along with increased aldosterone levels further enhances distal sodium reabsorption and prevents aldosterone escape 14. 