From the Guidelines
Lasix (furosemide) can worsen hepatorenal syndrome by reducing effective blood volume and renal perfusion in patients with advanced liver disease. When administered to patients with hepatorenal syndrome, Lasix increases diuresis which further depletes intravascular volume in patients who are already experiencing splanchnic vasodilation and relative hypovolemia 1. This reduction in effective circulating volume triggers compensatory mechanisms including activation of the renin-angiotensin-aldosterone system and sympathetic nervous system, leading to intense renal vasoconstriction. Additionally, Lasix can decrease cardiac output and mean arterial pressure, further compromising renal perfusion. The medication may also interfere with prostaglandin production in the kidneys, which normally helps maintain renal blood flow in cirrhotic patients.
According to the EASL clinical practice guidelines for the management of patients with decompensated cirrhosis, loop diuretics like Lasix should be used cautiously in patients with advanced liver disease and signs of hepatorenal syndrome 1. The guidelines recommend that patients with the first episode of grade 2 (moderate) ascites should receive an anti-mineralocorticoid drug alone, and furosemide should be added only in patients who do not respond to anti-mineralocorticoids or in patients who develop hyperkalemia.
Key considerations when using Lasix in patients with hepatorenal syndrome include:
- Monitoring changes in body weight, vital signs, serum creatinine, sodium, and potassium levels 1
- Avoiding excessive diuresis, which can lead to hypovolemia and worsen renal perfusion 1
- Discontinuing diuretics if severe hyponatremia, acute kidney injury, or worsening hepatic encephalopathy develop 1
- Using the lowest effective dose of diuretics to minimize the risk of complications 1
In general, loop diuretics like Lasix should be avoided or used very cautiously in patients with advanced liver disease and signs of hepatorenal syndrome, and alternative treatments such as anti-mineralocorticoid drugs should be considered as first-line therapy 1.
From the Research
Mechanism of Lasix in Hepatorenal Syndrome
- Lasix, also known as furosemide, is a loop diuretic that can exacerbate hepatorenal syndrome (HRS) by decreasing the effective circulating arterial volume 2.
- The use of furosemide in HRS patients can lead to a further decrease in renal perfusion, worsening the condition 2.
- In a study published in The American Journal of Gastroenterology, the administration of albumin and furosemide according to central venous pressure (CVP) showed improvement in renal function in some patients with HRS, but the need for furosemide varied from patient to patient 2.
Pathophysiology of Hepatorenal Syndrome
- HRS is a functional renal failure that develops in patients with advanced hepatic cirrhosis with ascites and in those with fulminant hepatic failure 3.
- The pathophysiologic cascade that leads to HRS begins with pooling of blood in the splanchnic system, resulting in a decrease in effective circulating arterial volume 4.
- The decrease in effective circulating arterial volume leads to a decrease in renal perfusion, resulting in renal failure 4.
Treatment of Hepatorenal Syndrome
- The definitive treatment of HRS is liver transplantation 4.
- When liver transplantation is not possible, HRS is treated with a combination of vasoconstrictor agents and intravenous albumin 4.
- Terlipressin, an analog of vasopressin, is likely to become the first-line standard of care for HRS, but norepinephrine can be used as an alternative treatment 5, 6.
- The use of midodrine and octreotide is also an option, but norepinephrine has been shown to be more effective in improving renal function in patients with HRS 5.