Can a diuretic be prescribed for a patient with end-stage renal disease (ESRD) undergoing hemodialysis?

Diuretics in ESRD Patients on Hemodialysis

Diuretics can and should be prescribed for ESRD patients on hemodialysis if they have substantial residual renal function (typically urine output ≥100 mL/day), as they provide meaningful clinical benefits including reduced interdialytic weight gain, lower mortality risk, and preservation of residual kidney function. 1

When to Prescribe Diuretics

Primary Indication: Preserved Residual Renal Function

• Loop diuretics are the agents of choice when residual renal function remains sufficient to respond to diuretic therapy 1, 2
• Therapy is effective only when daily urine output is at least 100 mL 1
• The K/DOQI guidelines explicitly state that diuretics cannot be recommended for blood pressure control in hemodialysis patients unless there is substantial residual kidney function that responds to diuretics 1

Clinical Benefits Demonstrated

• Patients on diuretics have almost twice the odds of retaining residual renal function after 1 year compared to those not on diuretics 3
• 14% lower cardiac-specific mortality risk (p=0.03) and 7% lower all-cause mortality risk in diuretic users 3
• Reduced interdialytic weight gain and lower odds of hyperkalemia (potassium >6.0 mmol/L) 3
• Preserved residual renal function is one of the most important predictors of patient survival 1

Practical Prescribing Algorithm

Step 1: Assess Residual Renal Function

• Measure 24-hour urine output or estimate based on daily voiding patterns 1
• If urine output <100 mL/day: diuretics are unlikely to be effective and should not be prescribed 1
• If urine output ≥100 mL/day: proceed to Step 2

Step 2: Select Appropriate Loop Diuretic

• Furosemide, bumetanide, or torsemide are the loop diuretics of choice 1, 2
• Higher doses are required due to pharmacokinetic changes with diminished renal clearance 2, 4
• Bumetanide has much lower incidence of ototoxicity compared to furosemide and torsemide 1

Step 3: Dosing Strategy

• Start with large doses of potent loop diuretics to promote sodium and water loss 1
• Titrate based on response, recognizing that ESRD patients require doses higher than those used in patients with normal renal function 2
• The effectiveness may not last long due to inevitable further decline in renal function 1

Critical Safety Considerations

Ototoxicity Risk

• Loop diuretics should be used with caution because of the possibility of dose-related ototoxicity 1
• Risk is greatest with furosemide and torsemide; much less with bumetanide 1
• Avoid concomitant use with other ototoxic medications 2

When NOT to Use Diuretics

• Automatically discontinuing diuretics at dialysis initiation is inappropriate if residual function exists 3
• However, diuretics provide minimal benefit in anuric patients and carry unnecessary risks 5
• In patients on maintenance dialysis without residual function, high-dose diuretics risk neurologic lesions, cramps, deafness, weakness, and muscle pain 5

Common Clinical Pitfall

The most common error is automatically stopping diuretics when patients start hemodialysis. 3 Data from the Dialysis Outcomes and Practice Patterns Study showed that diuretic use decreased sharply after dialysis initiation, with facility practices varying from 0% to 83.9% of patients—indicating widespread inconsistency in practice 3. Loop diuretic use ranged from only 9.2% in the United States to 21.3% in Europe, despite evidence of benefit 3.

Alternative Strategies for Volume Control

When diuretics are ineffective or contraindicated:

• Maximize ultrafiltration during dialysis sessions 1
• Enforce strict dietary sodium restriction (≤2g daily) 1
• Consider intensive hemodialysis regimens (short-daily, long nocturnal, or long-frequent) for patients with persistent volume overload 1
• Ultrafiltration or hemofiltration may be needed for diuretic-resistant fluid retention 1

Monitoring Requirements

• Watch for signs of ototoxicity, particularly with high doses or prolonged use 1, 2
• Monitor serum potassium if using potassium-sparing diuretics (though these can be safely administered with close monitoring) 2
• Reassess residual renal function periodically, as effectiveness diminishes with declining urine output 1