Do you use furosemide (Lasix) and spironolactone (Aldactone) in a patient with cirrhosis, Acute Kidney Injury (AKI), and ascites?

From the Guidelines

In patients with cirrhosis, Acute Kidney Injury (AKI), and ascites, diuretics such as furosemide and spironolactone should be temporarily discontinued until kidney function improves, as they can worsen kidney perfusion and exacerbate renal dysfunction 1. When considering the use of diuretics in these patients, it is essential to weigh the benefits of ascites management against the potential risks to renal function. The primary goal is to improve morbidity, mortality, and quality of life outcomes.

Key Considerations

• Diuretics should be used cautiously, if at all, in patients with AKI, as they can further compromise renal perfusion 2, 3, 1.
• The use of spironolactone and furosemide in combination may be considered once AKI resolves, with careful monitoring of renal function, electrolytes, and clinical response 3.
• The ratio of spironolactone to furosemide is typically maintained at 2.5:1 to 5:1 to maximize efficacy while minimizing electrolyte disturbances 2.
• Close monitoring of volume status is crucial to avoid hypovolemia and worsening renal function 1.
• Underlying causes of AKI should be addressed simultaneously, including treating infections, avoiding nephrotoxic medications, and considering albumin administration if appropriate 1.

Diuretic Management

• Spironolactone is initiated at a dose of 100 mg/day, with a maximum dose of 400 mg/day, and furosemide is started at 40 mg/day, with a maximum dose of 160 mg/day 3.
• Diuretic therapy should be adjusted based on response and electrolyte levels, with a maximum weight loss of 0.5 kg/day in patients without edema and 1 kg/day in patients with edema 1.
• Diuretics should be discontinued if severe hyponatremia, AKI, worsening hepatic encephalopathy, or incapacitating muscle cramps develop 1.

From the FDA Drug Label

WARNINGS In patients with hepatic cirrhosis and ascites, Furosemide tablets therapy is best initiated in the hospital. Supplemental potassium chloride and, if required, an aldosterone antagonist are helpful in preventing hypokalemia and metabolic alkalosis Aldosterone antagonist activity: Increased levels of the mineralocorticoid, aldosterone, are present in primary and secondary hyperaldosteronism. Edematous states in which secondary aldosteronism is usually involved include congestive heart failure, hepatic cirrhosis, and nephrotic syndrome By competing with aldosterone for receptor sites, Spironolactone provides effective therapy for the edema and ascites in those conditions.

Use of Furosemide and Spironolactone in a patient with cirrhosis, Acute Kidney Injury (AKI), and ascites:

• Furosemide can be used in patients with hepatic cirrhosis and ascites, but therapy should be initiated in the hospital.
• Spironolactone is effective in treating edema and ascites in patients with hepatic cirrhosis.
• The use of supplemental potassium chloride and an aldosterone antagonist (such as spironolactone) can help prevent hypokalemia and metabolic alkalosis in patients treated with furosemide.
• However, in the setting of Acute Kidney Injury (AKI), the use of furosemide and spironolactone should be approached with caution, as the benefits and risks of diuretic therapy in this context are not clearly defined in the provided drug labels [4] [5].
• Key considerations include the potential for worsening renal function, electrolyte imbalances, and the need for close monitoring of the patient's condition.

From the Research

Treatment of Ascites in Cirrhosis

• The treatment of ascites in cirrhosis is based on sodium restriction and the administration of diuretics 6.
• Spironolactone is the basic drug for the treatment of ascites, and the simultaneous administration of spironolactone and furosemide increases the natriuretic effect of each drug and diminishes their effects on potassium metabolism 6.
• The recommended initial dose is spironolactone 100-200 mg/d and furosemide 20-40 mg/d, with usual maximum doses of 400 mg/d of spironolactone and 160 mg/d of furosemide 7.

Use of Furosemide and Spironolactone in AKI

• In patients with cirrhosis and ascites, the use of furosemide and spironolactone can be effective in treating ascites, but the development of AKI requires careful consideration of the treatment approach 8.
• The study by 8 suggests that midodrine and albumin may be helpful in the secondary prophylaxis of AKI in patients with cirrhosis and ascites, but the use of furosemide and spironolactone in this context is not directly addressed.
• Another study 9 compared the efficacy and safety of xipamide and a combination of spironolactone and furosemide in the treatment of hepatic cirrhotic ascites, and found that the combination of spironolactone and furosemide was effective in treating ascites, but the study did not specifically address the use of these medications in patients with AKI.

Considerations for Treatment

• The treatment of ascites in cirrhosis should be individualized, taking into account the patient's underlying condition, including the presence of AKI 7, 6.
• The use of diuretics, including furosemide and spironolactone, should be carefully monitored, with attention to potential complications such as renal impairment and electrolyte imbalances 6, 9.
• In patients with refractory ascites, alternative treatments such as serial therapeutic paracentesis, transjugular intrahepatic stent-shunt (TIPS), or peritoneovenous shunt may be considered 7, 6.