No Clear Benefit of Fluid Restriction in Chronic Heart Failure: FRESH-UP Trial

The findings, published in Nature Medicine, challenge the traditional guideline that encourages fluid restriction for patients with chronic heart failure. Despite being a widely used recommendation, evidence supporting its efficacy has been limited. This study contributes valuable data, suggesting that allowing more liberal fluid intake does not worsen outcomes and may even reduce patient discomfort associated with thirst.

Fluid restriction is a common recommendation for patients with chronic heart failure; however, evidence from randomized clinical trials evaluating its true impact remains limited. To address this gap, Roland R. J. van Kimmenade, Department of Cardiology, Radboud University Medical Center, Nijmegen, the Netherlands, and colleagues conducted a multicenter open-label trial in which outpatients with chronic heart failure were randomly assigned to receive guidance either for liberal fluid intake or for restricting fluid consumption to a maximum of 1,500 ml per day.

The main goal of the trial was to evaluate patients' health status after three months, measured using the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OSS). The study also looked at secondary outcomes, including how much thirst patients experienced and any safety-related events.

The key findings of the study were as follows:

• A total of 504 patients were randomly assigned to two groups, with 67.3% being male.
• After 3 months, the average KCCQ-OSS score was 74.0 in the group allowed to drink more fluids and 72.2 in the fluid-restricted group.
• After adjusting for baseline values, the difference in scores between the two groups was 2.17 points, implying that the main goal of the study was not achieved.
• Patients in the fluid restriction group experienced more distress due to thirst.
• There were no significant differences in safety-related events between the two groups.

These results raise doubts about the effectiveness of fluid restriction in patients with chronic heart failure. Despite being commonly recommended, limiting fluid intake did not lead to meaningful improvements in patients’ health status or safety outcomes. Those who were restricted from drinking fluids experienced greater discomfort due to thirst, without any clear benefit.

"These findings suggest that a more liberal approach to fluid intake may be equally safe and potentially more comfortable for patients, and further research may help refine fluid management strategies in chronic heart failure care," the authors concluded.

Reference:

Herrmann, J. J., Baltussen, L. E., Bekkers, S. C., Bellersen, L., Van Eck, J. W., Hassing, H. C., Jaarsma, T., Linssen, G. C., Pisters, R., Verdijk, M. H., Handoko, M. L., Verbrugge, F. H., Januzzi, J. L., Nieuwlaat, R., Rodwell, L., Gommans, D. H., & Van Kimmenade, R. R. (2025). Liberal fluid intake versus fluid restriction in chronic heart failure: A randomized clinical trial. Nature Medicine, 1-7. https://doi.org/10.1038/s41591-025-03628-4