Can diuretics be administered to a patient with Impaired renal function undergoing dialysis (Renal Replacement Therapy)?

From the Guidelines

Diuretics can be administered to patients with impaired renal function undergoing dialysis, but their use requires careful consideration and monitoring, with loop diuretics like furosemide or torsemide being preferred over thiazide diuretics in advanced kidney disease. The decision to use diuretics in patients on dialysis depends on the patient's residual kidney function, volume status, and specific clinical situation, as stated in the guidelines by the European Society of Cardiology 1.

Key Considerations

• Patients with significant residual urine output (>200-300 mL/day) are more likely to benefit from diuretic therapy.
• Diuretics work by increasing urine output from remaining functional nephrons, which can help control fluid overload, hypertension, and edema between dialysis treatments.
• However, diuretics become less effective as kidney function declines, and they may not work at all in anuric patients.
• Close monitoring of electrolytes, especially potassium, is essential as diuretics can worsen electrolyte imbalances in dialysis patients, as noted in the guidelines by the American College of Cardiology 1.
• The dose and frequency of diuretics should be individualized based on the patient's response and residual kidney function, with the aim of achieving and maintaining euvolaemia with the lowest achievable dose, as recommended by the European Society of Cardiology 1.

Diuretic Options

• Loop diuretics: furosemide (20-160 mg daily) or torsemide (10-100 mg daily) may be prescribed to manage residual fluid overload between dialysis sessions.
• Thiazide diuretics generally have limited effectiveness in advanced kidney disease, but may be used in combination with loop diuretics for resistant oedema, with caution to avoid dehydration, hypovolaemia, hyponatraemia, or hypokalaemia, as stated in the guidelines by the European Society of Cardiology 1.

Monitoring and Adjustment

• Regular monitoring of electrolytes, especially potassium, is crucial to prevent worsening of electrolyte imbalances.
• The dose and frequency of diuretics should be adjusted based on the patient's response and residual kidney function, with the goal of achieving and maintaining euvolaemia with the lowest achievable dose, as recommended by the European Society of Cardiology 1.

From the FDA Drug Label

This drug is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Because elderly patients are more likely to have decreased renal function, care should be taken in dose selection and it may be useful to monitor renal function.

The administration of diuretics to a patient with impaired renal function undergoing dialysis (Renal Replacement Therapy) should be done with caution. The drug labels warn of the risk of toxic reactions in patients with impaired renal function, as diuretics are substantially excreted by the kidney.

• Key considerations:
  • Dose selection: should be cautious, usually starting at the low end of the dosing range
  • Monitoring: renal function should be monitored 2 3 4

From the Research

Diuretic Administration in Patients with Impaired Renal Function Undergoing Dialysis

• Diuretics can be administered to patients with impaired renal function undergoing dialysis, as they can help manage extracellular fluid volume and hypertension, and reduce the tendency to hyperkalemia 5, 6.
• Loop diuretics are generally the agents of choice in end-stage renal disease, but they need to be used at higher doses due to pharmacokinetic changes in the context of diminishing renal clearance 5, 7.
• 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 5.
• The use of diuretics in patients on haemodialysis can help lessen interdialytic weight gain, resulting in decreased ultrafiltration rates and fewer episodes of intradialytic hypotension 6.
• However, the use of diuretics in high dosage can be associated with risky side effects such as neurologic lesions, cramps, deafness, weakness, and muscle pain 7.
• International variations in diuretic use and loop diuretic dose have been reported, with some countries having higher utilization and doses than others 8.
• The prescription of higher doses of loop diuretics was not associated with improved outcomes, and may even be associated with a higher risk of all-cause hospitalization 8.
• Diuretic therapy can be beneficial in pre-dialysis CKD patients, but it is essential to weigh the benefits against the potential harms for each patient, and to avoid combination therapy and high doses of single diuretic therapy 9.