Do you hold furosemide and losartan in patients with Acute Kidney Injury (AKI)?

Management of Furosemide and Losartan in Acute Kidney Injury

In patients with AKI, immediately discontinue both furosemide and losartan unless the patient is hemodynamically stable with documented volume overload, in which case furosemide alone may be cautiously continued while losartan should still be held. 1, 2, 3

Losartan Management in AKI

Hold losartan immediately when AKI develops. The FDA label explicitly warns that drugs inhibiting the renin-angiotensin system can cause changes in renal function including acute renal failure, and recommends considering withholding or discontinuing therapy in patients who develop clinically significant decreases in renal function 3. This is particularly critical because:

• Patients whose renal function depends on the renin-angiotensin system (including those with volume depletion, severe heart failure, or chronic kidney disease) are at particular risk of developing acute renal failure on losartan 3
• Combining furosemide with ACE inhibitors or ARBs leads to severe hypotension and deterioration in renal function, including renal failure 4
• An interruption or reduction in dosage of ARBs is necessary when AKI develops 4

The KDIGO conference identified determining the optimal timing of ACE-I/ARB discontinuation and re-initiation in AKI as a critical research priority, acknowledging current uncertainty 5. However, the FDA guidance is clear: hold the medication when clinically significant renal function decline occurs 3.

Furosemide Management in AKI

When to Hold Furosemide

Discontinue furosemide immediately in the following situations: 1, 2

• Hemodynamically unstable patients (furosemide precipitates volume depletion, hypotension, and further renal hypoperfusion) 1, 2
• Oliguria with serum creatinine >3 mg/dL 1
• Dialysis-dependent renal failure 1
• Within 12 hours after last fluid bolus or vasopressor administration 1
• Cirrhotic patients with new-onset AKI (withdraw all diuretics as first-line management) 1, 2

When Furosemide May Be Continued

Furosemide should only be used in hemodynamically stable patients with AKI who have documented volume overload 1, 2. The KDIGO guidelines provide a Level 2C recommendation that diuretics should not be used to treat AKI except for managing volume overload 1, 2.

Key evidence supporting selective use:

• In patients with volume overload, higher furosemide doses had a protective effect on mortality specifically in AKI patients with volume overload 1
• Furosemide was associated with improved short-term survival in critically ill AKI patients, especially those with AKI UO stage 2-3 6
• However, furosemide was not effective in patients with AKI SCr stage 2-3 or chronic kidney disease 6

Critical Pitfalls to Avoid

Never use furosemide to "reverse" established AKI or convert oliguric to non-oliguric AKI—this practice lacks evidence of benefit and causes harm through fluid overload and worsening kidney function 1, 2. The KDIGO guidelines provide a Level 1B recommendation against using diuretics to prevent AKI, based on randomized controlled trials demonstrating that furosemide does not prevent AKI and may actually increase mortality 1, 2.

Additional concerns:

• Furosemide is associated with worsening renal function, with patients receiving 60 mg greater total daily doses showing deterioration 1
• Each nephrotoxic medication combined with furosemide increases AKI odds by 53% 1, 2
• Adverse events, mostly electrolyte abnormalities, are more common in furosemide-treated patients 7

Monitoring Requirements if Furosemide Continued

If furosemide must be used for documented volume overload in stable AKI patients: 1, 2

• Monitor hourly urine output 1, 2
• Assess daily renal function (serum creatinine, BUN) 1, 2
• Check electrolytes every 12-24 hours 1, 2
• Reassess volume status after administration 1
• Ensure adequate intravascular volume before administration 8

Dosing Adjustments

For heart failure patients with AKI requiring furosemide for volume overload: 2

• Start with 20 mg IV for new-onset heart failure or patients not on chronic diuretics 2
• For patients on chronic diuretics, use at least equivalent to home oral dose 2
• Consider reducing dose by 25-50% if AKI is significant 2

Algorithm for Decision-Making

1. Assess hemodynamic stability: If unstable → hold both medications 1, 2, 3
2. Assess volume status: If no volume overload → hold both medications 1, 2
3. If stable with volume overload: Hold losartan; may continue furosemide with intensive monitoring 1, 2, 3
4. Special populations (cirrhosis): Withdraw both immediately regardless of volume status 1, 2
5. Monitor closely: If worsening renal function → discontinue furosemide 1, 2