Do you use furosemide (Lasix) and spironolactone (Aldactone) in a patient with cirrhosis, Acute Kidney Injury (AKI), and hepatic encephalopathy, but no ascites?

From the Guidelines

In a patient with cirrhosis who has acute kidney injury (AKI) and hepatic encephalopathy but no ascites, I would generally avoid using furosemide and spironolactone. These diuretics should not be used in this clinical scenario as they may worsen the AKI and potentially exacerbate hepatic encephalopathy, as suggested by the most recent guidelines 1. Instead, the focus should be on identifying and treating the underlying cause of the AKI, such as addressing potential prerenal causes (volume depletion, hypotension), intrinsic renal injury, or hepatorenal syndrome.

For hepatic encephalopathy management, lactulose (typically 25-30 mL every 6-12 hours, titrated to 2-3 soft bowel movements daily) and rifaximin (550 mg twice daily) would be more appropriate. Diuretics would only be indicated if there was evidence of fluid overload or ascites. In cirrhosis with AKI, careful volume status assessment is crucial, and nephrotoxic medications should be discontinued. If hepatorenal syndrome is suspected, vasoconstrictors like norepinephrine or terlipressin (where available) along with albumin may be necessary, as recommended by recent guidelines 1. Regular monitoring of renal function, electrolytes, and mental status is essential in managing these complex patients.

Some key points to consider in the management of these patients include:

• The importance of volume status assessment and the potential need for albumin infusion in patients with cirrhosis and AKI, as highlighted in recent studies 1
• The role of vasoconstrictors in the treatment of hepatorenal syndrome, as discussed in the literature 1
• The need for careful monitoring of renal function, electrolytes, and mental status in patients with cirrhosis and AKI, as emphasized in the guidelines 1
• The potential risks and benefits of diuretic use in patients with cirrhosis and AKI, as outlined in the evidence 1

Overall, the management of patients with cirrhosis, AKI, and hepatic encephalopathy requires a careful and individualized approach, taking into account the latest evidence and guidelines 1.

From the FDA Drug Label

In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital. Spironolactone can cause sudden alterations of fluid and electrolyte balance which may precipitate impaired neurological function, worsening hepatic encephalopathy and coma in patients with hepatic disease with cirrhosis and ascites. The risk of adverse reactions to spironolactone may be greater in patients with impaired renal function. Patients with renal impairment are at increased risk of hyperkalemia.

The use of furosemide and spironolactone in a patient with cirrhosis, Acute Kidney Injury (AKI), and hepatic encephalopathy, but no ascites, is not directly supported by the FDA drug labels.

• The labels recommend cautious use in patients with hepatic cirrhosis and renal impairment.
• Furosemide and spironolactone may worsen hepatic encephalopathy and increase the risk of hyperkalemia in patients with renal impairment.
• The labels do not provide guidance on the use of these medications in patients with AKI and hepatic encephalopathy without ascites 2, 2, 3.

From the Research

Patient Treatment Considerations

• The use of furosemide (Lasix) and spironolactone (Aldactone) in a patient with cirrhosis, Acute Kidney Injury (AKI), and hepatic encephalopathy, but no ascites, is a complex decision that requires careful consideration of the patient's overall condition and the potential risks and benefits of these medications 4, 5, 6, 7, 8.
• Furosemide is frequently used to treat ascites in patients with cirrhosis, but it can cause adverse reactions, including electrolyte disturbances, volume depletion, and coma, particularly in patients with prior hepatic encephalopathy 8.
• Spironolactone is also used to treat ascites in patients with cirrhosis, and it may be a safer alternative to furosemide in some cases, as it requires less dose adjustment and may have a lower risk of adverse reactions 4.
• However, the use of diuretics, including furosemide and spironolactone, in patients with AKI and hepatic encephalopathy requires careful monitoring and adjustment of doses to avoid worsening of kidney function and exacerbation of hepatic encephalopathy 5, 6, 7.

Potential Risks and Benefits

• The potential benefits of using furosemide and spironolactone in this patient include the treatment of ascites and the management of fluid overload, which can help to improve the patient's overall condition and reduce the risk of complications 4, 5.
• However, the potential risks of using these medications in a patient with AKI and hepatic encephalopathy include the worsening of kidney function, exacerbation of hepatic encephalopathy, and the development of adverse reactions, such as electrolyte disturbances and coma 6, 7, 8.
• Therefore, the decision to use furosemide and spironolactone in this patient should be made on a case-by-case basis, taking into account the patient's individual needs and circumstances, and with careful monitoring and adjustment of doses as needed 4, 5, 6, 7, 8.