Furosemide Uses in CKD/AKI
Furosemide should be used primarily for managing volume overload in CKD/AKI patients, but should not be used to prevent or treat AKI itself except in cases of volume overload. 1
Indications for Furosemide in CKD/AKI
Volume Management
- Furosemide is indicated for treatment of edema associated with renal disease, including nephrotic syndrome 2, 3
- In patients with CKD who have volume overload, furosemide can be used to manage fluid accumulation and associated symptoms 2
- For patients with AKI and fluid overload, furosemide may be used to help achieve fluid balance, particularly in those requiring mechanical ventilation 4
Diagnostic Applications
- The furosemide stress test (FST) can help predict progression of AKI and need for renal replacement therapy 5
- An intravenous dose of 1.0-1.5 mg/kg furosemide with subsequent urine output >100 ml/h suggests GFR >20 ml/min and lower likelihood of progression to severe AKI 5
Contraindications and Cautions
Not for AKI Prevention
- KDIGO guidelines strongly recommend (1B evidence) not using diuretics to prevent AKI 1
- Randomized controlled trials and meta-analyses demonstrate that furosemide does not prevent AKI and may increase mortality when used for prevention 1
Not for AKI Treatment Without Volume Overload
- KDIGO suggests (2C evidence) not using diuretics to treat AKI except in the management of volume overload 1
- In cardiac surgery patients, furosemide administration has no significant effect on AKI incidence or need for renal replacement therapy 6
Dosing Considerations in Renal Disease
- Patients with parenchymal renal disease (e.g., diabetic nephropathy, IgA nephropathy) may require dose adjustments of diuretic combinations 1
- In patients with severe bilateral renal artery stenosis, there is risk of acute renal failure with diuretic use 1
Practical Administration
Dosing
- For management of edema in renal disease, initial oral dosing is typically 20-80 mg/day, which can be increased based on response 1
- Intravenous furosemide should be reserved for patients unable to take oral medication or in emergency clinical situations 2
- Parenteral use should be replaced with oral furosemide as soon as practical 2
Monitoring
- Monitor electrolytes (particularly potassium) shortly after initiating therapy and periodically thereafter 1
- Assess renal function regularly, as high doses of intravenous furosemide (80 mg) can cause acute reduction in renal perfusion and subsequent azotemia 1
- Monitor for signs of hypovolemia, which can worsen renal function in patients with AKI 4
Special Considerations
Combination Therapy
- In resistant cases, combination with other diuretic classes may be necessary 1
- Spironolactone may be used in combination with furosemide, but patients with CKD may tolerate less spironolactone due to hyperkalemia risk 1
Pediatric Considerations
- In critically ill children, furosemide exposure has been associated with reduced fluid accumulation but potentially increased mortality risk 7
- Careful monitoring is essential when using furosemide in pediatric patients with AKI 7
Potential Benefits Beyond Volume Control
- In patients with acute lung injury without hemodynamic instability, furosemide may facilitate mechanical ventilation according to lung-protective ventilation strategies 4
- Furosemide administration in cardiac surgical patients may reduce postoperative blood urea nitrogen levels, mechanical ventilation duration, and ICU length of stay 6
Common Pitfalls
- Overreliance on furosemide to "protect" or "rescue" kidneys in AKI without addressing the underlying cause 1
- Inadequate monitoring of volume status, leading to hypovolemia and worsening renal function 4
- Failure to adjust doses in patients with severe renal impairment 1
- Neglecting to monitor electrolytes, particularly in patients on combination diuretic therapy 1