What diuretic is recommended for a patient with impaired renal function refusing dialysis?

From the Guidelines

Loop diuretics, particularly furosemide, are the recommended diuretic for patients with impaired renal function who refuse dialysis, with a typical starting dose of 20-40mg orally once or twice daily, which can be titrated up to 600mg daily in severe cases, as stated in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. The choice of diuretic is crucial in patients with impaired renal function, and loop diuretics have been shown to be effective in managing fluid overload in these patients.

• The mechanism of action of loop diuretics, which work at the thick ascending limb of the loop of Henle, allows them to remain effective even at low glomerular filtration rates, unlike thiazide diuretics which lose effectiveness when creatinine clearance falls below 30-40 ml/min.
• According to the 2022 AHA/ACC/HFSA guideline, the initial daily dose of furosemide can be 20-40mg once or twice, with a maximum total daily dose of 600mg 1.
• Combination therapy with a thiazide-like diuretic such as metolazone (2.5-10mg daily) may be considered for resistant cases to achieve sequential nephron blockade, as suggested in the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1.
• Regular monitoring of electrolytes, particularly potassium, sodium, and magnesium, is essential as these patients are at high risk for electrolyte disturbances, and careful assessment of volume status and daily weight monitoring should be implemented to guide therapy and prevent over-diuresis.
• The 2022 AHA/ACC/HFSA guideline also notes that diuretic resistance can be overcome in several ways, including escalation of loop diuretic dose, intravenous administration of diuretics, or combination of different diuretic classes 1.

From the FDA Drug Label

Edema associated with chronic renal failure The recommended initial dose is 20 mg oral torsemide tablets once daily. If the diuretic response is inadequate, titrate upward by approximately doubling until the desired diuretic response is obtained. Doses higher than 200 mg have not been adequately studied In single-dose studies in patients with non-anuric renal failure, high doses of torsemide (20 mg to 200 mg) caused marked increases in water and sodium excretion. In patients with non-anuric renal failure, severe enough to require hemodialysis, chronic treatment with up to 200 mg of daily torsemide has not been shown to change steady-state fluid retention

The recommended diuretic for a patient with impaired renal function refusing dialysis is torsemide, with an initial dose of 20 mg oral torsemide tablets once daily. The dose can be titrated upward by approximately doubling until the desired diuretic response is obtained, but doses higher than 200 mg have not been adequately studied 2.

From the Research

Diuretic Options for Patients with Impaired Renal Function Refusing Dialysis

• Loop diuretics, such as furosemide, bumetanide, and torasemide, are powerful drugs capable of increasing sodium excretion and urine output even when renal function is markedly impaired 3.
• Torasemide is a new loop diuretic that has a high bioavailability and a plasma half-life that remains unchanged in chronic renal failure, making it an effective option for patients with advanced renal failure 4, 5.
• The use of loop diuretics in patients with chronic renal failure may be helpful in controlling extracellular volume expansion responsible for hypertension, especially when impaired renal function co-exists with nephrotic syndrome or chronic heart failure 3.
• Torasemide has been shown to be as potent as furosemide in patients with advanced renal failure, with a longer half-life independent of renal function and no indications of toxic side effects 4, 5.

Advantages of Torasemide

• Torasemide has a longer half-life independent of renal function, making it a more convenient option for patients with impaired renal function 4, 5.
• Torasemide has no indications of toxic side effects, reducing the risk of adverse effects in patients with impaired renal function 4, 5.
• Torasemide has a more pronounced antihypertensive effect compared to furosemide, making it a useful option for patients with hypertension and impaired renal function 5.

Clinical Use of Diuretics in Patients with Impaired Renal Function

• Diuretics can continue to play a role in managing extracellular fluid volume and hypertension in patients with impaired renal function, even if they are refusing dialysis 6.
• Loop diuretics are generally the agents of choice in end-stage renal disease, but may need to be used at higher doses due to pharmacokinetic changes in the context of diminishing renal clearance 6.
• Other classes of diuretics can still be used in end-stage renal disease, but usually in conjunction with loop diuretics or for benefits independent of diuresis 6.