Is Lasix (furosemide) 20mg being withheld in a patient with End-Stage Renal Disease (ESRD) and mild hyponatremia, given a sodium level of 133 mEq/L, which was 131 mEq/L yesterday?

From the Guidelines

I would not recommend holding the Lasix (furosemide) 20mg at this time, as your sodium level has improved slightly and the benefits of managing fluid overload in ESRD patients outweigh the risks of mild hyponatremia. Your sodium level has actually improved slightly from 131 to 133 mEq/L, which is approaching the normal range (typically 135-145 mEq/L) 1. For patients with ESRD (End-Stage Renal Disease), mild hyponatremia (low sodium) is common and often doesn't require stopping diuretics if the levels are stable or improving. Lasix helps manage fluid overload in ESRD patients, which is important for controlling blood pressure and preventing complications like pulmonary edema. According to the 2009 ACCF/AHA Heart Failure Guidelines, if electrolyte imbalances are seen, these should be treated aggressively and the diuresis continued 1.

The key points to consider in this scenario are:

• The patient's sodium level is improving, which suggests that the current treatment is effective
• The patient has ESRD, which requires careful management of fluid overload to prevent complications
• The use of diuretics, such as Lasix, is recommended in patients with fluid retention, unless contraindicated, to improve symptoms 1
• The patient should continue to monitor their sodium levels closely and stay in communication with their nephrologist to adjust the treatment plan as needed

It is also important to note that excessive concern about hypotension and azotemia can lead to the underutilization of diuretics and a state of refractory edema, which can limit the efficacy and compromise the safety of other drugs used for the treatment of HF 1. Therefore, it is crucial to maintain diuresis until fluid retention is eliminated, even if this strategy results in mild or moderate decreases in blood pressure or renal function, as long as the patient remains asymptomatic. If the patient's sodium levels drop below 130 mEq/L or they experience symptoms like confusion, headache, nausea, or muscle cramps, they should contact their healthcare provider immediately as their medication may need adjustment.

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. If increasing azotemia and oliguria occur during treatment of severe progressive renal disease, Furosemide tablets should be discontinued.

The patient has End-Stage Renal Disease (ESRD), which is a severe and progressive condition. Given the patient's mild hyponatremia with a sodium level of 133 mEq/L, which was 131 mEq/L yesterday, and considering the potential risks of electrolyte imbalance and worsening renal function, it is prudent to exercise caution.

• The FDA drug label recommends discontinuing Furosemide in patients with severe progressive renal disease if increasing azotemia and oliguria occur.
• There is no direct information in the label that supports withholding or continuing Lasix (furosemide) 20mg in this specific patient. However, considering the patient's condition and the potential risks, a conservative clinical decision would be to withhold Lasix (furosemide) 20mg to avoid potential worsening of renal function and electrolyte imbalance. 2 2

From the Research

Patient's Condition

The patient has End-Stage Renal Disease (ESRD) and mild hyponatremia with a sodium level of 133 mEq/L, which was 131 mEq/L yesterday.

Treatment Considerations

• The patient's sodium level is slightly above the threshold for hyponatremia, and the change from yesterday is minimal.
• According to the study 3, asymptomatic mild hyponatremia is treated with adequate solute intake and initial fluid restriction, with adjustments based on serum sodium levels.
• The study 4 suggests that furosemide with or without sodium chloride supplementation did not show benefits in correcting hyponatremia compared to fluid restriction alone in patients with SIAD.
• However, the study 5 reports that combination therapy with low-dose metolazone and furosemide can be effective in managing refractory fluid overload in elderly renal failure patients under palliative care.

Furosemide Administration

• The study 6 demonstrates that metolazone significantly potentiates the diuretic effects of furosemide, allowing for lower doses of furosemide and simplifying the treatment of fluid retention.
• The study 7 recommends early, aggressive administration of a loop diuretic, such as furosemide, for patients with acute decompensated heart failure, but does not provide specific guidance for patients with ESRD and mild hyponatremia.

Decision to Withhold Furosemide

• Given the patient's mild hyponatremia and minimal change in sodium level, withholding furosemide 20mg may be considered, especially if the patient is asymptomatic and fluid restriction is being implemented.
• However, the decision to withhold furosemide should be made on a case-by-case basis, taking into account the patient's overall clinical condition and response to treatment, as suggested by the studies 4, 5, and 3.