What is the effect of Hydrochlorothiazide (HCTZ) in Acute Kidney Injury (AKI)?

From the Guidelines

Hydrochlorothiazide (HCTZ) should not be given in acute kidney injury (AKI). HCTZ is a thiazide diuretic that works by inhibiting sodium reabsorption in the distal convoluted tubule, which requires adequate kidney function to be effective. In AKI, kidney function is compromised, making HCTZ ineffective and potentially harmful. Using HCTZ during AKI can worsen the kidney injury by causing further dehydration, electrolyte imbalances (particularly hyponatremia, hypokalemia, and hypercalcemia), and reduced renal perfusion.

Key Points to Consider

• The most recent and highest quality study, 1, recommends not using diuretics to prevent AKI, and suggests not using diuretics to treat AKI, except in the management of volume overload.
• Loop diuretics like furosemide (20-40mg IV) are generally preferred for diuresis in AKI as they remain somewhat effective even with reduced kidney function, as noted in 1 and 1.
• HCTZ should be temporarily discontinued in patients who develop AKI and can be reconsidered once kidney function has recovered to baseline.
• The underlying cause of AKI should be addressed while ensuring adequate hydration, monitoring electrolytes, and avoiding other nephrotoxic medications, as suggested in 1 and 1.

Management of AKI

• The KDIGO guideline, as discussed in 1, provides recommendations for the prevention and treatment of AKI, including the use of isotonic crystalloids, vasopressors, and protocol-based management of hemodynamic and oxygenation parameters.
• Monitoring of renal function, electrolytes, and fluid status is crucial in the management of AKI, as emphasized in 1.

From the Research

HCTZ in Acute Kidney Injury (AKI)

• The use of diuretics, including HCTZ, in AKI is a topic of debate, with some studies suggesting that they may not provide significant benefits in terms of mortality or renal function 2, 3.
• HCTZ is a thiazide diuretic that is sometimes used in combination with loop diuretics to manage fluid overload in patients with AKI 2.
• However, there is no conclusive evidence to support the use of HCTZ in AKI, and its effectiveness in improving patient outcomes is unclear 4, 5.
• One study found that diuretics, including HCTZ, may be associated with an increased risk of AKI, particularly when used in combination with other nephrotoxic agents 6.

Clinical Considerations

• The management of AKI is largely supportive, and the use of diuretics, including HCTZ, should be individualized based on the patient's clinical condition and response to treatment 2, 5.
• Patients with AKI who are treated with HCTZ should be closely monitored for signs of worsening renal function, electrolyte imbalance, and other adverse effects 3, 6.
• The dosage and duration of HCTZ treatment in AKI should be carefully considered, as high doses and prolonged use may increase the risk of adverse effects 6.

Pathological Analysis

• The pathological lesions associated with HCTZ-induced AKI are not well characterized, but may include vacuolar degeneration of tubular epithelial cells 6.
• The severity of AKI and the risk of non-complete recovery may be predicted by factors such as age, gender, and RIFLE classification 6.