What is the best diuretic to use in patients with chronic kidney disease (CKD)?

Best Diuretic for Chronic Kidney Disease

Loop diuretics are the first-line diuretic choice for patients with chronic kidney disease (CKD), with torsemide being preferred due to its longer duration of action and once-daily dosing, which improves medication adherence in patients with moderate-to-severe CKD (GFR <30 mL/min). 1

Loop Diuretics as First-Line Therapy

• Loop diuretics remain effective even with markedly impaired renal function and are preferred over thiazides in patients with GFR <30 mL/min 1
• Twice daily dosing is generally preferred over once daily dosing to maximize effectiveness, though daily dosing may be acceptable for reduced GFR in nephrotic syndrome 2
• Loop diuretics are critical for managing fluid overload and hypertension commonly encountered in CKD patients 3

Specific Loop Diuretic Recommendations

• Torsemide is the preferred loop diuretic in CKD due to:

  • Longer duration of action (12-16 hours) compared to furosemide's 6-8 hours 1
  • Once-daily dosing improving medication adherence 1
  • Maximum daily dose of 200 mg 1

• Furosemide considerations:

  • Shorter duration of action (6-8 hours) requiring more frequent dosing 1
  • Maximum daily dose of 600 mg 1
  • Consider switching to longer-acting loop diuretics like bumetanide or torsemide if concerned about treatment failure or oral bioavailability 2

• Bumetanide can be considered as an alternative:

  • Duration of action of 4-6 hours 1
  • Maximum daily dose of 10 mg 1

Dosing and Administration Strategies

• Increase dose of loop diuretic until clinically significant diuresis is achieved or maximum effective dose has been reached 2
• For resistant edema, continuous intravenous infusion of furosemide has significantly better natriuretic and diuretic effect than bolus administration in patients with advanced CKD 4
• Loop diuretics may need higher doses in advanced CKD due to reduced kidney perfusion and fewer nephron sites for drug action 1

Combination Therapy for Resistant Edema

• For resistant edema, add mechanistically different diuretics for synergistic effect:
  • Add thiazide-like diuretics to loop diuretics to impair distal sodium reabsorption 2, 1
  • Consider amiloride to counter hypokalemia and improve diuresis 2, 1
  • Consider spironolactone to improve edema/hypertension management and counter hypokalemia from loop or thiazide diuretics 2
  • Acetazolamide may be helpful for metabolic alkalosis but is a weak diuretic 2

Monitoring and Adverse Effects

• Monitor for adverse effects of diuretics:

  • Hypokalemia with thiazide and loop diuretics 2, 1
  • Hyponatremia with thiazide diuretics 2, 1
  • Impaired GFR 2
  • Hyperkalemia with spironolactone and eplerenone, especially if combined with RAS blockade 2, 1
  • Volume depletion, especially in pediatric/elderly patients 2

• Check serum potassium and renal function within 2-4 weeks of initiation or increase in dose 1

Adjunctive Measures

• Restrict dietary sodium to <2.0 g/d (<90 mmol/d) to enhance diuretic efficacy 2, 1
• For patients with both hypertension and proteinuria, ACEi or ARB should be used as first-line therapy, with diuretics added as needed 2, 1

Common Pitfalls to Avoid

• Failing to increase loop diuretic dose in advanced CKD 1
• Not considering reduced bioavailability of oral diuretics in patients with edema 1
• Neglecting to monitor magnesium levels, as hypomagnesemia can make hypokalemia resistant to correction 1
• Stopping ACEi or ARB therapy unless serum creatinine rises by more than 30% within 4 weeks following initiation of treatment 2