What is the management of fluid overload and hypertension in patients with kidney diseases using diuretics?

Management of Fluid Overload and Hypertension in Kidney Disease Using Diuretics

Adults with hypertension and chronic kidney disease (CKD) should be treated to a blood pressure goal of less than 130/80 mmHg, with diuretics playing a crucial role in managing fluid overload and blood pressure control. 1

First-Line Approach for Fluid Overload

• Loop diuretics are the first-line therapy for treating edema and fluid overload in patients with kidney disease 1
• Twice daily dosing of loop diuretics is preferred over once daily dosing, though daily dosing may be acceptable for patients with reduced GFR in nephrotic syndrome 1
• Increase the dose of loop diuretic to cause clinically significant diuresis or until maximally effective dose has been reached 1
• Consider switching to longer-acting loop diuretics such as bumetanide or torsemide if concerned about treatment failure with furosemide or if oral drug bioavailability is a concern 1

Combination Therapy for Resistant Edema

• For resistant edema, combine loop diuretics with other mechanistically different diuretics for synergistic effect 1
• Thiazide diuretics administered with an oral or IV loop diuretic will impair distal sodium reabsorption and improve diuretic response 1
• Amiloride may provide improvement in edema/hypertension and counter hypokalemia from loop or thiazide diuretics 1
• Spironolactone may improve edema/hypertension and counter hypokalemia from loop or thiazide diuretics 1, 2
• Acetazolamide may help treat metabolic alkalosis but is a weak diuretic and should be used with caution in impaired renal function 1, 3

Blood Pressure Management in CKD

• Target systolic blood pressure in most adult patients with CKD should be <130/80 mmHg using standardized office BP measurement 1
• Use an ACE inhibitor or ARB to maximally tolerated or allowed dose as first-line therapy in treating patients with both hypertension and proteinuria 1
• Do not stop ACE inhibitor or ARB with modest and stable increase in serum creatinine (up to 30%) 1
• Stop ACE inhibitor or ARB if kidney function continues to worsen and/or refractory hyperkalemia develops 1

Monitoring and Adverse Effects

• Monitor for adverse effects of diuretics including hypokalemia with thiazide and loop diuretics, hyponatremia with thiazide diuretics, impaired GFR, and volume depletion 1, 4
• Hyperkalemia is a risk with spironolactone, especially if combined with RAS blockade 1, 2
• Volume depletion is a particular concern in pediatric and elderly patients 1
• Thiazide diuretics can cause dilutional hyponatremia, which may be life-threatening in edematous patients in hot weather 4

Strategies for Diuretic-Resistant Patients

• Consider loop diuretics in combination with IV albumin for resistant cases 1
• Loop diuretics (bolus or infusion) alone may be effective 1
• Consider ultrafiltration or hemodialysis in severe cases unresponsive to medical management 1
• Amiloride may reduce potassium loss and improve diuresis in resistant cases 1

Special Considerations in Advanced CKD

• Loop diuretics are often more effective than thiazides for volume control at lower glomerular filtration rates 5
• Avoid combination diuretic therapy in advanced CKD when possible, as it may lead to greater decline in eGFR 6
• Diuretic dosing should be adjusted based on kidney function to avoid adverse effects while maintaining efficacy 7
• In peritoneal dialysis patients with residual kidney function, high-dose loop diuretics can enhance urinary sodium and water removal 1

Cautions and Pitfalls

• Inappropriate use of high doses of diuretics can lead to volume contraction, increasing the risk of hypotension and renal insufficiency 1
• Diuretic therapy should be carefully monitored in CKD as it may worsen electrolyte imbalance and kidney function 5
• Avoid starting ACE inhibitors or ARBs in patients who present with abrupt onset of nephrotic syndrome as these drugs can cause acute kidney injury, especially in patients with minimal change disease 1
• Careful monitoring of serum electrolytes, particularly potassium, is essential when using potassium-sparing diuretics like spironolactone 2

By following these guidelines for diuretic use in managing fluid overload and hypertension in kidney disease, clinicians can optimize patient outcomes while minimizing adverse effects.