Should Lasix Be Held in Mild AKI?
Do not hold furosemide in mild AKI if the patient has volume overload and is hemodynamically stable; however, immediately discontinue furosemide if the patient lacks volume overload, is hemodynamically unstable, or has cirrhosis with new-onset AKI. 1, 2, 3
Primary Guideline Recommendations
The KDIGO guidelines provide clear direction on furosemide use in AKI:
Furosemide should NOT be used to prevent or treat AKI itself (Level 1B recommendation), as randomized controlled trials demonstrate it does not prevent AKI and may increase mortality. 1, 2
Furosemide should ONLY be used for managing volume overload in AKI patients (Level 2C recommendation), not for treating the kidney injury itself. 1, 2, 3
The potential benefit of furosemide in non-volume overloaded AKI patients is outweighed by risks of precipitating volume depletion, hypotension, and further renal hypoperfusion. 1, 3
Clinical Decision Algorithm
When to CONTINUE Furosemide:
- Patient has documented volume overload (pulmonary edema, peripheral edema, elevated CVP). 2, 3
- Patient is hemodynamically stable with adequate blood pressure. 2, 3
- Consider reducing dose by 25-50% if AKI is significant. 3
When to IMMEDIATELY DISCONTINUE Furosemide:
- Patient lacks volume overload. 2, 3
- Patient is hemodynamically unstable. 1, 3
- Patient has cirrhosis with new-onset AKI (withdraw immediately per International Club of Ascites). 4, 3
- Patient develops severe hyponatremia, worsening hepatic encephalopathy, or incapacitating muscle cramps. 2
Evidence on Furosemide and Renal Function
Furosemide is associated with worsening renal function, with studies showing patients who developed worsening renal function received 60 mg greater total daily dose (199 mg vs 143 mg) compared to those without deterioration. 2, 3
Each nephrotoxic medication (including furosemide) increases AKI odds by 53%, particularly when combined with other nephrotoxins. 4, 2, 3
The FDA label warns that if increasing azotemia and oliguria occur during treatment of severe progressive renal disease, furosemide should be discontinued. 5
Monitoring Requirements if Continuing Furosemide
- Monitor hourly urine output during IV diuretic therapy. 2, 3
- Assess daily renal function (serum creatinine, BUN). 4, 2
- Check electrolytes every 12-24 hours during IV diuretic therapy. 4, 2, 3
- Reassess volume status after diuretic administration. 4
Special Considerations for Dosing
- For patients with new-onset heart failure or not on chronic diuretics, start with lower dose of 20 mg IV furosemide. 3
- For patients already on chronic diuretic therapy, initial IV dose should be at least equivalent to home oral dose. 3
- Consider dose reduction of 25-50% if AKI is significant. 3
Critical Pitfalls to Avoid
Never use furosemide to convert oliguric to non-oliguric AKI—this practice lacks evidence of benefit and may cause harm. 2, 3
Do not use furosemide in hemodynamically unstable patients, as it can precipitate further volume depletion and renal hypoperfusion. 1, 4, 3
Avoid combining furosemide with other nephrotoxic medications (aminoglycosides, NSAIDs, ACE inhibitors), as this substantially increases AKI risk. 4, 2, 3, 5
Furosemide Stress Test Consideration
The furosemide stress test (FST) can predict progression to stage 3 AKI with AUC values of 0.87-0.93, but should only be performed after ensuring adequate intravascular volume. 4
FST should not be performed in hemodynamically unstable patients. 4
If urine output is <200 mL in first 2 hours after FST, anticipate progression to stage 3 AKI and prepare for potential RRT. 4