From the Guidelines
For a patient with third spacing who has received Lasix and albumin but now shows an elevated BUN/creatinine ratio, I would recommend considering the use of terlipressin, as it is the vasoactive drug of choice in the treatment of hepatorenal syndrome (HRS) and can help improve renal function, as suggested by the most recent evidence 1. The elevated BUN/creatinine ratio suggests pre-renal azotemia, likely from excessive diuresis or continued third spacing.
- Start with a fluid bolus of 500-1000 mL of isotonic solution over 1-2 hours, then reassess volume status and adjust to a maintenance rate.
- Monitor urine output, vital signs, and daily weights closely.
- Consider repeating albumin (25% solution, 50-100 mL) if the patient has hypoalbuminemia contributing to the third spacing, as albumin can help support oncotic pressure and mobilize third-spaced fluid back into the vasculature, although the need for continuation of albumin should be assessed carefully based on volume status 1.
- Temporarily hold further diuretics until renal function improves. This approach addresses the underlying volume depletion while supporting oncotic pressure to help mobilize third-spaced fluid back into the vasculature.
- Electrolyte replacement, particularly potassium and magnesium, may be necessary as these are often depleted with diuretic use and can affect renal function. It is essential to note that the use of terlipressin and albumin should be guided by the patient's volume status and renal function, and the decision to continue or stop these treatments should be made based on the patient's individual response, as suggested by the evidence 1.
From the FDA Drug Label
Reversible elevations of BUN may occur and are associated with dehydration, which should be avoided, particularly in patients with renal insufficiency The patient's elevated BUN/cr ratio may be due to dehydration caused by Lasix (furosemide) therapy. To help the patient, consider addressing the dehydration and monitoring electrolyte levels.
- Ensure adequate fluid replacement to prevent dehydration.
- Monitor serum electrolytes, particularly potassium, and correct any abnormalities.
- Consider potassium supplements and/or dietary measures to control or avoid hypokalemia 2. Note that the use of furosemide and albumin may not be directly related to the elevated BUN/cr ratio, but dehydration caused by furosemide could be a contributing factor.
From the Research
Patient Treatment Options
To address the patient's condition of third spacing, with a higher BUN/cr ratio after receiving Lasix and albumin, the following options can be considered:
- Administering another dose of furosemide (Lasix) as the diuretic effect of furosemide can be enhanced when combined with albumin in patients with hypoalbuminemia, as shown in studies 3, 4
- Monitoring the patient's response to the current treatment and adjusting the dosage or adding other diuretics if necessary, considering the patient's renal function and the potential for diuretic resistance 5
- Evaluating the patient's BUN and serum creatinine levels together to determine the cause of the elevated BUN/cr ratio, as an extrarenal problem can produce a ratio of greater than 25:1, while renal failure produces a ratio of 10:1 6
Considerations for Edema Management
In patients with nephrotic syndrome, the combination of albumin and a loop diuretic, such as furosemide, may improve edema by increasing diuresis and natriuresis 7
- The response to this combination therapy can vary, and the underlying physiology of diuresis and natriuresis should be considered when managing edema in these patients
- The use of albumin and furosemide in combination may be beneficial in patients who do not respond to diuretics alone, as it can enhance the diuretic effect and improve edema management 3, 4