Is a urine output of 104oz in 24 hours acceptable for a patient on 40mg Torsemide and 100mg Spironolactone?

Urine Output Assessment on Torsemide and Spironolactone

A 24-hour urine output of 104 oz (approximately 3 liters) is acceptable and represents an appropriate diuretic response for a patient on 40mg torsemide and 100mg spironolactone, assuming the patient has peripheral edema. 1

Target Diuretic Response

The acceptability of this urine output depends critically on whether the patient has peripheral edema:

• With peripheral edema: There is no strict limit to weight loss per day, and 3 liters of urine output is reasonable 1
• Without peripheral edema: Maximum recommended weight loss is 0.5 kg/day, which corresponds to approximately 500 mL of net fluid loss 1

The key metric is not absolute urine output but rather net fluid balance and weight loss. 1

Monitoring Parameters Beyond Volume

Rather than focusing solely on urine volume, assess the following:

• Urinary sodium excretion: Should exceed 78 mmol/day to indicate adequate diuretic response 1
• Spot urine sodium:potassium ratio: A ratio between 1.8-2.5 predicts adequate 24-hour sodium excretion with 87.5% sensitivity 1
• Weight loss: Target 1 kg/day if edema present, 0.5 kg/day if no edema 1

Medication Dosing Context

The current regimen is within guideline-recommended ranges:

• Spironolactone 100mg: This is the standard starting dose, with maximum doses up to 400mg/day 1
• Torsemide 40mg: This is equivalent to furosemide 40mg (the standard loop diuretic starting dose when combined with spironolactone), though torsemide can be increased further if needed 1, 2

The 100:40 ratio of spironolactone to loop diuretic maintains normokalemia and is the recommended starting combination. 1

Critical Safety Monitoring

Temporarily discontinue diuretics if any of the following occur: 1

• Serum sodium <125 mmol/L (severe hyponatremia)
• Worsening hypokalemia or hyperkalemia
• Rising serum creatinine indicating acute kidney injury
• Hepatic encephalopathy
• Severe muscle cramps

Warning Signs of Excessive Diuresis

Hypovolemic hyponatremia from overzealous diuretic therapy is characterized by: 1

• Prolonged negative sodium balance
• Marked extracellular fluid loss
• Requires cessation of diuretics and plasma volume expansion with normal saline

Practical Assessment

To determine if this urine output is appropriate:

1. Check daily weight: Is the patient losing 0.5-1 kg/day (depending on edema status)? 1
2. Measure spot urine sodium:potassium ratio: Is it between 1.8-2.5? 1
3. Monitor electrolytes: Is sodium >125 mmol/L and potassium 3.5-5.5 mmol/L? 1
4. Assess clinical status: Is peripheral edema or ascites improving without symptoms of volume depletion? 1

If all parameters are favorable, the current urine output of 104 oz (3 liters) represents an effective and safe diuretic response. 1