What are the implications of diuretic use in patients with Chronic Kidney Disease (CKD)?

From the Guidelines

Diuretics should be used cautiously in patients with chronic kidney disease (CKD), with loop diuretics being the preferred option for most CKD patients, especially those with moderate to severe disease. According to the most recent and highest quality study 1, loop diuretics such as furosemide (20-80mg once or twice daily), bumetanide (0.5-2mg daily), or torsemide (10-100mg daily) are appropriate choices, with torsemide offering better oral bioavailability and longer duration of action. Thiazide diuretics like hydrochlorothiazide (12.5-50mg daily) or chlorthalidone (12.5-25mg daily) are generally less effective in advanced CKD (eGFR <30 mL/min/1.73m²) but may be used in mild CKD.

Key Considerations

• Potassium-sparing diuretics such as spironolactone should be used with extreme caution due to hyperkalemia risk and are typically avoided when eGFR is below 30 mL/min/1.73m² 1.
• When initiating diuretic therapy, start with lower doses and titrate gradually while monitoring renal function, electrolytes (particularly potassium and sodium), and blood pressure.
• Combination therapy with loop and thiazide diuretics may be necessary for resistant edema but requires close monitoring, as the risk of adverse effects including electrolyte imbalances, worsening kidney function, and ototoxicity increases in CKD patients 1.
• The European Society of Cardiology (ESC) guidelines suggest that the aim of diuretic therapy is to achieve and maintain euvolaemia with the lowest achievable dose, and that patients can be trained to self-adjust their diuretic dose based on monitoring of symptoms/signs of congestion and daily weight measurements 1.

Monitoring and Adjustments

• Regular monitoring of renal function, electrolytes, and blood pressure is essential to minimize the risk of adverse effects and to adjust diuretic therapy as needed.
• The dose of the diuretic must be adjusted according to the individual needs over time, taking into account the patient's response to therapy and any changes in renal function or electrolyte balance.

From the FDA Drug Label

As with any effective diuretic, electrolyte depletion may occur during furosemide therapy, especially in patients receiving higher doses and a restricted salt intake In patients with hypoproteinemia (e.g., associated with nephrotic syndrome) the effect of furosemide may be weakened and its ototoxicity potentiated. Reversible elevations of BUN may occur and are associated with dehydration, which should be avoided, particularly in patients with renal insufficiency

The use of furosemide in patients with chronic kidney disease requires careful monitoring due to the potential for electrolyte depletion and dehydration, which can worsen renal insufficiency.

• Patients with nephrotic syndrome may experience a weakened effect of furosemide and increased ototoxicity.
• Laboratory tests, including serum electrolytes and creatinine, should be performed frequently to monitor for potential adverse effects 2.
• Hypokalemia and other electrolyte imbalances should be corrected promptly to avoid complications.
• Patients with renal insufficiency should be monitored closely for signs of dehydration and electrolyte imbalance.

From the Research

Diuretic Use in Patients with Chronic Kidney Disease

• Diuretics are commonly used in patients with chronic kidney disease (CKD) to control extracellular fluid volume, reduce protein excretion in urine, and prevent hyperkalemia 3.
• The use of diuretics in CKD patients can be beneficial in managing hypertension, vascular congestion, and hyperkalemia, but it is not without complications, such as intravascular volume depletion, azotemia, and electrolyte imbalances 4.
• Different classes of diuretics, including thiazide-type diuretics, loop diuretics, and K(+)-sparing diuretics, can be used to treat CKD patients, either individually or in combination therapies 3, 5.

Types of Diuretics Used in CKD

• Thiazide and thiazide-type diuretics are foundational therapies for the management of hypertension in CKD patients 5, 6.
• Loop diuretics, such as furosemide, are often used to manage volume overload in CKD patients and can be effective even in advanced CKD 5, 7.
• Mineralocorticoid receptor antagonists can be used to manage diuretic-resistant volume overload or treatment-resistant hypertension in CKD patients 5.

Benefits and Complications of Diuretic Use in CKD

• Diuretics can increase urinary volume and sodium excretion in CKD patients, which can help manage hypertension and volume overload 7.
• However, diuretic use can also lead to complications, such as electrolyte abnormalities, intravascular volume depletion, and azotemia 4, 6.
• Close monitoring of electrolyte levels and renal function is necessary when using diuretics in CKD patients 6.