Should furosemide (Lasix) be held in a patient with Acute Kidney Injury (AKI)?

Should Furosemide Be Held in Acute Kidney Injury?

Furosemide should generally be held in patients with AKI unless they have documented volume overload and are hemodynamically stable. 1

Primary Recommendation Based on Highest Quality Evidence

The KDIGO guidelines provide a Level 1B recommendation against using diuretics to prevent AKI, based on randomized controlled trials and meta-analyses demonstrating that furosemide does not prevent AKI and may actually increase mortality. 1 More importantly, diuretics should not be used to treat AKI except for managing volume overload (Level 2C recommendation). 1

When to Absolutely Hold Furosemide

Withhold diuretic therapy in the following situations:

• Renal failure defined as dialysis dependence 2
• Oliguria with serum creatinine >3 mg/dL 2
• Oliguria with serum creatinine 0-3 mg/dL with urinary indices indicative of acute renal failure 2
• Until 12 hours after last fluid bolus or vasopressor given 2
• Hemodynamically unstable patients - furosemide may precipitate volume depletion, hypotension, and further renal hypoperfusion 3
• Cirrhotic patients with new-onset AKI - furosemide should be withdrawn immediately 3

The FDA label warns that if increasing azotemia and oliguria occur during treatment of severe progressive renal disease, furosemide should be discontinued. 4

When Furosemide May Be Considered

Furosemide should only be used in hemodynamically stable patients with AKI who have documented volume overload. 1 The evidence suggests potential benefit in specific circumstances:

• High CVP (≥12 mm Hg) with early oliguric AKI: Recent 2023 data shows furosemide use within 6 hours of AKI diagnosis was associated with lower risk of progression to stage 3 AKI (OR 0.40,95% CI 0.25-0.65) and reduced 28-day mortality (OR 0.47,95% CI 0.25-0.92) specifically in patients with CVP ≥12 mm Hg. 5

• ARDS patients without shock: Conservative fluid management protocols recommend furosemide for patients with CVP >8 mmHg (or PAOP >12 mmHg) and adequate urine output, after ensuring mean arterial pressure ≥60 mmHg and off vasopressors ≥12 hours. 2

Critical Evidence on Harm

Furosemide is associated with worsening renal function - patients who developed worsening renal function received a 60 mg greater total daily dose of furosemide (199 mg vs 143 mg) compared to those without deterioration. 1 Additionally, combining furosemide with other nephrotoxic medications increases AKI odds by 53% per nephrotoxin. 1, 3

A 2017 pilot RCT (SPARK study) found that furosemide did not reduce worsening AKI (43.2% vs 37.1%, p=0.6), did not improve kidney recovery (29.7% vs 42.9%, p=0.3), and did not reduce need for RRT (27.0% vs 28.6%, p=0.8), but was associated with significantly more electrolyte abnormalities (p<0.001). 6

Common Pitfalls to Avoid

Never use diuretics to convert oliguric to non-oliguric AKI - this practice lacks evidence of benefit and may cause harm. 1 The goal is not to increase urine output for its own sake, but rather to manage volume overload when present.

Do not perform furosemide stress test in unstable patients - while the FST can predict AKI progression (AUC 0.87-0.93), it should only be performed after ensuring adequate intravascular volume and never in hemodynamically unstable patients. 3

Monitoring Requirements If Furosemide Is Used

When furosemide must be used for volume overload in stable AKI patients:

• Monitor hourly urine output 1
• Check electrolytes every 12-24 hours 1, 3, 4
• Assess daily renal function (serum creatinine, BUN) 1, 4
• Reassess volume status after administration 2

The FDA label emphasizes that serum electrolytes (particularly potassium), CO2, creatinine and BUN should be determined frequently during the first few months of therapy and periodically thereafter. 4

Special Population: Cirrhosis

In cirrhotic patients, discontinue diuretics immediately if severe hyponatremia, AKI, worsening hepatic encephalopathy, or incapacitating muscle cramps develop. 1 The International Club of Ascites recommends withdrawing all diuretics as a first-line management step for cirrhotic patients with AKI stage 1. 1

Algorithm for Decision-Making

1. Is the patient hemodynamically stable? If NO → Hold furosemide 1, 3
2. Does the patient have documented volume overload? If NO → Hold furosemide 1
3. Is serum creatinine >3 mg/dL with oliguria? If YES → Hold furosemide 2
4. Is the patient on dialysis? If YES → Hold furosemide 2
5. Has it been <12 hours since last fluid bolus or vasopressor? If YES → Hold furosemide 2
6. Does the patient have cirrhosis with new AKI? If YES → Hold furosemide 3
7. If all above are satisfied AND volume overload is present → Consider furosemide with close monitoring 1