What are the considerations for using Lasix (furosemide) in patients with End-Stage Renal Disease (ESRD)?

Furosemide Use in End-Stage Renal Disease (ESRD)

High doses of furosemide (up to 1000 mg/day) can be effective in ESRD patients with residual renal function to manage fluid overload, though effectiveness is limited compared to patients with better kidney function. While furosemide has reduced efficacy in ESRD, it can still provide clinical benefit in specific situations.

Pharmacokinetics in ESRD

• Elimination half-life of furosemide is significantly prolonged in ESRD patients (200 ± 57 minutes) compared to healthy individuals (51 ± 7.7 minutes) 1
• Total plasma clearance in functionally anephric patients is reduced (54 ± 18 ml/min) 1
• Reduced renal excretion necessitates dose adjustments

Efficacy in ESRD Patients

Patients on Hemodialysis

• Furosemide at doses of 500-1000 mg/day can significantly decrease weight gain between dialysis sessions and increase sodium excretion 2
• Even small doses (40 mg) in patients with residual renal function can double urinary volume (1142 ± 184 vs. 453 ± 135 ml/24h) and sodium excretion (112 ± 22.4 vs. 45.2 ± 16.0 mEq/24h) compared to no diuretic use 3

Patients on Peritoneal Dialysis

• Furosemide did not show statistically significant improvement in urine volume or preservation of residual renal function in peritoneal dialysis patients after one year 4
• However, fewer patients on furosemide became anuric at one year (5% vs. 22% in control group) 4

Dosing Considerations

• For patients with creatinine clearance <30 ml/minute or receiving hemodialysis, the dose should be reduced to 250-500 mg/day 5
• High doses (up to 720 mg/day orally or up to 1400 mg/day intravenously) may be required in resistant cases 6
• EMB should be administered at a dose of 15-20 mg/kg three times a week by DOT after dialysis in patients with end-stage renal disease 5

Monitoring Requirements

• Careful monitoring of electrolytes (particularly potassium), CO₂, creatinine, and BUN is essential 7, 8
• Monitor for signs of fluid or electrolyte imbalance: dry mouth, thirst, weakness, lethargy, drowsiness, muscle cramps, hypotension, oliguria, tachycardia, arrhythmias 7, 8
• Assess for hypovolemia, which can worsen renal function 9

Risks and Precautions

• Excessive diuresis may cause dehydration and blood volume reduction with circulatory collapse, particularly in elderly patients 7, 8
• Hypokalemia may develop, especially with brisk diuresis or inadequate oral electrolyte intake 7, 8
• Increases in blood glucose and alterations in glucose tolerance tests have been observed 7, 8
• Furosemide may increase the ototoxic potential of aminoglycoside antibiotics, especially with impaired renal function 7, 8

Clinical Decision Algorithm

1. Assess residual renal function:

   • If patient has measurable urine output, furosemide may provide benefit
   • If completely anuric, furosemide will have minimal to no effect

2. Determine appropriate dose:

   • Start with 250-500 mg/day in ESRD patients with residual function
   • Consider higher doses (up to 1000 mg/day) in resistant cases

3. Monitor response:

   • Measure urine output, weight changes between dialysis sessions
   • Assess for improvement in edema and fluid overload symptoms

4. Adjust based on response:

   • If inadequate response, consider increasing dose
   • If no response despite high doses, consider discontinuation

5. Regular monitoring:

   • Check electrolytes, particularly potassium
   • Monitor for signs of dehydration or hypovolemia
   • Assess for adverse effects (ototoxicity, hypotension)

Remember that while furosemide may help manage fluid balance in ESRD patients with residual function, its effectiveness is significantly reduced compared to patients with better kidney function, and the risk of adverse effects remains.