From the Guidelines
Lasix (furosemide) is generally not recommended for patients on dialysis who have bilateral lower extremity (BLE) edema, as it has limited effectiveness in patients with end-stage renal disease on dialysis due to its requirement for functioning kidneys to work properly. For dialysis patients, fluid overload and edema are typically managed through the dialysis process itself by removing excess fluid during treatments. According to the clinical practice guidelines for hemodialysis adequacy, update 2006 1, diuretic use should be approached with caution in dialysis patients.
The primary approach to managing edema in dialysis patients should be optimizing the ultrafiltration during dialysis sessions, potentially with more frequent dialysis or longer sessions if needed. If medication is necessary between dialysis sessions, it should be prescribed only after consultation with the patient's nephrologist, as they may recommend a higher dose of loop diuretics (if any residual kidney function exists) or alternative approaches specific to the dialysis patient's condition.
Some key points to consider when managing edema in dialysis patients include:
- Optimizing ultrafiltration during dialysis sessions to remove excess fluid
- Potentially increasing the frequency or duration of dialysis sessions
- Consulting with the patient's nephrologist before prescribing any medication
- Being cautious when using diuretics in dialysis patients due to the risk of electrolyte imbalances, hypotension, and other complications
Using diuretics inappropriately in dialysis patients can lead to electrolyte imbalances, hypotension, and other complications without effectively addressing the underlying fluid management issues. The 2022 AHA/ACC/HFSA guideline for the management of heart failure 1 provides information on the use of diuretics in patients with heart failure, but it is essential to consider the specific context of dialysis patients when managing edema.
In general, the management of edema in dialysis patients requires a careful and individualized approach, taking into account the patient's residual kidney function, dialysis schedule, and overall medical condition. By prioritizing ultrafiltration during dialysis sessions and consulting with the patient's nephrologist, healthcare providers can help ensure effective management of edema and minimize the risk of complications in dialysis patients.
From the FDA Drug Label
In patients with severe symptoms of urinary retention (because of bladder emptying disorders, prostatic hyperplasia, urethral narrowing), the administration of furosemide can cause acute urinary retention related to increased production and retention of urine. In patients at high risk for radiocontrast nephropathy, furosemide can lead to a higher incidence of deterioration in renal function after receiving radiocontrast compared to high-risk patients who received only intravenous hydration prior to receiving radiocontrast. Furosemide is indicated in adults and pediatric patients for the treatment of edema associated with congestive heart failure, cirrhosis of the liver, and renal disease, including the nephrotic syndrome
The patient has bilateral leg edema and impaired renal function and is undergoing dialysis.
- Furosemide can be used to treat edema associated with renal disease.
- However, caution is advised in patients with impaired renal function as furosemide can lead to deterioration in renal function.
- The use of furosemide in patients undergoing dialysis is not directly addressed in the label, but its use in patients with renal disease is indicated.
- Therefore, furosemide can be ordered for bilateral leg edema in a patient with impaired renal function undergoing dialysis, but with close monitoring of renal function and caution due to the potential for deterioration in renal function 2 2.
From the Research
Ordering Lasix (Furosemide) for Bilateral Leg Edema
- Lasix (furosemide) is a loop diuretic that can be used to treat edema, including bilateral leg edema, in patients with impaired renal function undergoing dialysis 3.
- However, caution should be exercised when using furosemide in combination with other diuretics, such as metolazone, as it can lead to severe electrolyte disturbances, including hyponatremia, hypochloremia, alkalosis, and hypokalemia 4.
- In patients with end-stage renal disease, precise regulation of fluid and electrolytes is crucial, and diuretics like furosemide can be used to manage fluid overload, but careful monitoring of electrolyte levels and fluid status is necessary 5.
- Combination therapy with low-dose metolazone and furosemide has been shown to be effective in managing refractory fluid overload in elderly renal failure patients under palliative care, without the need for parenteral diuretics 6.
- It is essential to note that dialysis disequilibrium syndrome with cerebral edema is a rare but life-threatening complication that can occur in patients undergoing dialysis, and careful monitoring and management of fluid and electrolyte balance are crucial to prevent this condition 7.