From the Guidelines
In patients with chronic kidney disease (CKD), loop diuretics like furosemide (Lasix) are generally preferred over thiazide diuretics like hydrochlorothiazide (HCTZ), especially as kidney function declines. For patients with mild to moderate CKD (stages 1-3), HCTZ may still be effective at doses of 12.5-50 mg daily, as suggested by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. However, once the glomerular filtration rate (GFR) falls below approximately 30 mL/min (stage 4 CKD), HCTZ becomes significantly less effective. At this point, switching to furosemide is recommended, typically starting at 20-40 mg once or twice daily, with dose adjustments based on response, as indicated in the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary 1.
Some key points to consider when using diuretics in CKD patients include:
- Monitoring for electrolyte imbalances, particularly potassium, sodium, and magnesium
- Adjusting doses based on response and kidney function
- Considering combination therapy or higher doses of furosemide for resistant edema
- Maintaining moderate dietary sodium restriction
- Regularly assessing and adjusting diuretic therapy to prevent recurrence of volume overload, as recommended in the 2013 ACCF/AHA guideline for the management of heart failure 1.
It's essential to prioritize the patient's kidney function, blood pressure, and overall clinical status when selecting and adjusting diuretic therapy, and to consult the most recent and highest-quality guidelines, such as the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1, to inform treatment decisions.
From the Research
Comparison of HCTZ and Lasix in CKD Patients
- HCTZ and Lasix (furosemide) are both diuretics used to manage hypertension and fluid overload in patients with chronic kidney disease (CKD) 2, 3, 4, 5.
- A study comparing the effects of switching from high-dose angiotensin receptor blockers to a combination of normal-dose telmisartan and low-dose HCTZ in hypertensive patients with CKD found that the combination therapy was more efficacious in reducing blood pressure and urinary protein excretion 2.
- Another study examined the renoprotective effects of combination therapy with thiazides (including HCTZ) and loop diuretics (including Lasix) in patients with type 2 diabetic kidney disease and found that the combination improved blood pressure levels and decreased proteinuria 3.
- A review of CKD diagnosis and management noted that diuretics, including thiazides and loop diuretics, are important in managing sodium and volume overload in patients with CKD 6.
- A study comparing furosemide and HCTZ in patients with hypertension and stage 4 or 5 CKD found that both diuretics decreased mean blood pressure by the same extent, but the association of the two diuretics was more efficient on blood pressure 5.
- The use of diuretics in patients with CKD is based on the principle of enhancing urinary sodium excretion to manage sodium and volume overload, with thiazide and thiazide-type diuretics being foundational therapies for hypertension and loop diuretics being used for volume overload 4.
Efficacy and Safety of HCTZ and Lasix in CKD Patients
- The efficacy of HCTZ and Lasix in reducing blood pressure and proteinuria in CKD patients has been demonstrated in several studies 2, 3, 5.
- The safety of HCTZ and Lasix in CKD patients has also been evaluated, with one study finding no significant change in the estimated glomerular filtration rate and serum creatinine level after switching to a combination of normal-dose telmisartan and low-dose HCTZ 2.
- Another study found no adverse metabolic effects of HCTZ even among diabetic patients 2.
- The combination of HCTZ and loop diuretics has been found to improve blood pressure levels and decrease proteinuria in patients with type 2 diabetic kidney disease, without negatively affecting the change in estimated glomerular filtration rate 3.