What is the recommended use of Furosemide (Lasix) in patients with Acute Kidney Injury (AKI)?

Furosemide Use in Acute Kidney Injury

Furosemide should not be used to prevent or treat acute kidney injury (AKI) except in cases of volume overload, as it does not prevent AKI and may potentially increase mortality. 1

General Recommendations for Furosemide in AKI

• Diuretics including furosemide should not be used to prevent AKI (level 1B recommendation) 1
• Furosemide should not be used to treat AKI except in the management of volume overload (level 2C recommendation) 1
• Despite preclinical studies showing potential benefit, randomized controlled trials and meta-analyses demonstrate that furosemide does not prevent AKI and may lead to increased mortality 1
• In cases where volume overload complicates AKI, diuretics may actually improve outcomes 1

Appropriate Clinical Scenarios for Furosemide in AKI

• Use furosemide only in hemodynamically stable patients with AKI who have volume overload 1
• In patients with acute pulmonary edema and AKI, furosemide may be appropriate for managing volume overload 1, 2
• The FDA indicates that parenteral furosemide is appropriate when rapid onset of diuresis is desired (e.g., in acute pulmonary edema) but does not specifically recommend it for AKI treatment 2

Risks and Monitoring

• Furosemide administration is associated with worsening renal function, with studies showing a 60 mg greater total dose of furosemide the day before in patients who developed worsening renal function 1
• Excessive diuresis may cause dehydration and blood volume reduction with circulatory collapse, particularly in elderly patients 2
• Electrolyte abnormalities are common adverse events with furosemide use in AKI patients 3
• Regular monitoring is essential during IV diuretic therapy, including:
  • Hourly urine output monitoring 4
  • Daily renal function assessment 4, 2
  • Electrolyte monitoring every 12-24 hours 4, 2

Predictors of Response to Furosemide in AKI

• Measured creatinine clearance is the strongest predictor of urinary output response to furosemide in AKI patients 5
• Both altered pharmacokinetics and reduced pharmacodynamic response become important when creatinine clearance is reduced to less than 40 mL/min/1.73 m² 5
• AKI staging and markers of intravascular volume (central venous pressure, brain-natriuretic-peptide concentration, fractional urinary sodium excretion) are not reliable predictors of response to furosemide 5

Special Considerations

• For heart failure patients with AKI, consider starting with a lower dose of 20 mg IV furosemide for patients with new-onset heart failure or those not on chronic diuretics 4
• For patients already on chronic diuretic therapy, the initial IV dose should be at least equivalent to their home oral dose 4
• Consider reducing the dose by 25-50% if AKI is significant 4
• Avoid combining furosemide with other nephrotoxic medications, as each nephrotoxin administration presents a 53% greater odds of developing AKI 1
• Recent research suggests furosemide administration may be associated with improved short-term survival and recovery of renal function in some critically ill patients with AKI, particularly those with oliguria, but not in those with severe AKI by creatinine criteria or those with chronic kidney disease 6

Pitfalls and Caveats

• Using furosemide in hemodynamically unstable patients with AKI can precipitate volume depletion, hypotension, and further renal hypoperfusion 1
• The potential benefit of furosemide in non-volume overloaded AKI patients is outweighed by risks 1
• Pilot randomized controlled trials have shown that furosemide did not reduce the rate of worsening AKI, improve recovery, or reduce the need for renal replacement therapy, but was associated with greater electrolyte abnormalities 3
• Patients with hypoproteinemia may experience weakened effects of furosemide and increased ototoxicity 2