From the Guidelines
Furosemide can be used in heart failure patients with an estimated glomerular filtration rate (eGFR) as low as 20 mL/min/1.73m², as seen in the EMPULSE trial 1. For patients with an eGFR of 30-60 mL/min/1.73m², standard dosing can often be used with careful monitoring. When eGFR falls below 30 mL/min/1.73m², consider starting with lower doses (20-40 mg daily) and titrating based on response. Some key points to consider when using furosemide in heart failure patients include:
- Monitoring symptoms, urine output, renal function, and electrolytes during use of i.v. diuretics, as recommended by the 2016 ESC guidelines 1.
- Giving diuretics either as intermittent boluses or as a continuous infusion, with dose and duration adjusted according to patients’ symptoms and clinical status 1.
- Considering combination of loop diuretic with either thiazide-type diuretic or spironolactone in patients with resistant hypertension or severe volume overload 1. In severe renal impairment (eGFR <15 mL/min/1.73m²), furosemide may have limited efficacy and higher doses (80-160 mg) might be needed, though the risk of toxicity increases. Regular monitoring of renal function, electrolytes (particularly potassium, sodium, and magnesium), and volume status is essential. Furosemide works by inhibiting sodium reabsorption in the loop of Henle, but its delivery to the kidney tubules is dependent on renal blood flow and secretion into the tubular lumen, both of which are compromised in severe renal impairment. This explains why higher doses may be needed as renal function declines, though the risk-benefit ratio must be carefully assessed in each patient. The most recent and highest quality study, the EMPULSE trial 1, supports the use of furosemide in heart failure patients with an eGFR as low as 20 mL/min/1.73m².
From the Research
Furosemide Use in Heart Failure
- Furosemide is a commonly used diuretic in the treatment of heart failure, but its use must be carefully considered in patients with renal dysfunction 2, 3.
- The estimated glomerular filtration rate (eGFR) is an important factor in determining the safety of furosemide use in heart failure patients 2, 3.
EGFR Level and Furosemide Use
- A study published in 2012 found that high daily doses of furosemide were associated with increased mortality in patients with chronic systolic heart failure, and that reduced eGFR was a predictor of poor outcome 2.
- Another study published in 2021 found that continuous infusion of furosemide was more effective than bolus injection in patients with acute decompensated heart failure and moderate chronic renal insufficiency (eGFR 15.0-44.9 mL/min/1.73 m2) 3.
- However, there is no specific EGFR level that is considered "safe" for furosemide use, as the decision to use furosemide should be based on individual patient factors and clinical judgment 2, 3, 4.
Comparison with Other Diuretics
- A systematic review and meta-analysis published in 2021 compared the effects of furosemide with other diuretics in the treatment of heart failure, and found that azosemide and torasemide caused a significant reduction in brain natriuretic peptide (BNP) level 4.
- However, no significant difference was found between furosemide and other diuretics in terms of glomerular filtration rate (GFR), water extraction, and sodium excretion 4.
Ultrafiltration as an Alternative
- Ultrafiltration is a promising alternative to diuretics in the treatment of heart failure, particularly in patients with cardiorenal syndrome 5, 6.
- A systematic review and meta-analysis published in 2015 found that ultrafiltration was a safe and effective strategy in the treatment of cardiorenal syndrome, without increasing the risk of renal deterioration 6.