Is it acceptable to continue loop diuretic (e.g. furosemide) therapy in the presence of possible acute kidney injury (AKI)?

From the Guidelines

Continuing loop diuretics during possible kidney injury requires careful consideration and should generally be approached with caution, as these medications can potentially worsen kidney function by reducing blood flow to the kidneys and causing further dehydration 1. In most cases, loop diuretics should be temporarily held or reduced when acute kidney injury (AKI) is suspected. However, the decision isn't always straightforward. If the patient has significant volume overload, pulmonary edema, or heart failure exacerbation, continuing diuretics may be necessary despite mild kidney injury. In such cases, close monitoring of kidney function, electrolytes (particularly potassium, sodium, and magnesium), and volume status is essential. Dosing adjustments may be needed based on the severity of kidney dysfunction. The underlying cause of the kidney injury should be identified and addressed promptly, which might include treating infections, discontinuing nephrotoxic medications, or correcting hemodynamic abnormalities. Some key points to consider when managing patients with possible kidney injury on loop diuretics include:

• Monitoring serum electrolytes, urea nitrogen, and creatinine during titration of HF medications, including diuretics 1
• Adjusting diuretic dose based on the severity of kidney dysfunction and the patient's volume status
• Considering alternative diuretic strategies, such as adding a second diuretic or using continuous infusion therapy 1
• Nephrology consultation is advisable for complex cases where the balance between managing fluid overload and protecting kidney function is challenging. Remember that kidney injury from pre-renal causes (like dehydration) typically improves with fluid resuscitation, which would contradict the use of diuretics. It is also important to note that the use of loop diuretics can lead to electrolyte disturbances, such as hypokalemia, and that monitoring of electrolyte levels is essential to prevent these complications 1.

From the FDA Drug Label

If increasing azotemia and oliguria occur during treatment of severe progressive renal disease, Furosemide tablets should be discontinued. If increasing azotemia and oliguria occur during treatment of severe progressive renal disease, furosemide should be discontinued.

It is not OK to continue loop diuretic with possible kidney injury. The drug labels for furosemide 2, 2, and 3 indicate that the medication should be discontinued if there are signs of worsening renal function, such as increasing azotemia and oliguria.

From the Research

Loop Diuretics and Kidney Injury

• Loop diuretics are commonly used in patients with acute kidney injury (AKI) to manage complications such as volume overload and electrolyte imbalances 4, 5, 6.
• The use of loop diuretics in AKI has been shown to increase urine output and reduce the duration of renal replacement therapy (RRT) 7.
• However, loop diuretics may not improve mortality or renal recovery in patients with AKI 7.
• The furosemide stress test has been proposed as a tool to identify patients with AKI who are at higher risk of progression and may require RRT 4, 5.

Risks and Benefits

• The use of loop diuretics in patients with AKI may be associated with risks such as volume depletion, reduced renal perfusion, and worsening kidney function 5.
• However, loop diuretics may also have benefits such as reducing pulmonary edema and improving urine output 4, 6.
• The balance between the risks and benefits of loop diuretics in patients with AKI needs to be carefully considered, and the decision to continue or discontinue loop diuretics should be made on a case-by-case basis 8, 7.

Clinical Practice

• A survey of clinicians found that loop diuretics are frequently used in patients with AKI, and that furosemide is the most commonly used loop diuretic 6.
• Clinicians reported that they use loop diuretics to manage volume overload, pulmonary edema, and electrolyte imbalances, and to improve urine output 6.
• However, there is a need for higher quality evidence on the use of loop diuretics in AKI, and for randomized controlled trials to determine the optimal use of loop diuretics in this population 6, 7.