From the Guidelines
Furosemide should be used with caution in patients with chronic kidney disease (CKD), as it can cause dose-dependent renal decline and increased risk of mortality, particularly in those with worsening renal function (WRF) 1. When using furosemide in CKD patients, it is essential to start with lower doses (20-40mg daily) and titrate based on response, as CKD patients may have altered drug metabolism and increased risk of side effects.
- Key considerations for furosemide use in CKD include:
- Monitoring for electrolyte imbalances (especially potassium, sodium, and calcium)
- Dehydration and worsening kidney function
- Regular laboratory monitoring of kidney function, electrolytes, and blood pressure
- Potential need for combination with thiazide diuretics in resistant edema
- Caution in patients with sulfa allergies and those taking other nephrotoxic medications The pharmacokinetics of furosemide in CKD patients show a maximal effect within 1.5 hours of the first oral dose, with reduced effect with repeated doses 1.
- Factors to consider when using furosemide in CKD patients include:
- Reduced kidney perfusion, leading to reduced rate of excretion of diuretic into the renal tubules
- Progressive nephron loss in CKD, resulting in fewer sites at which the diuretics can act
- Increased half-life in CKD, leading to resistance to the diuretic and requiring increasing doses over time
- Potential reduced bioavailability of oral diuretics due to gut wall edema in heart failure patients Regular monitoring of renal function and careful dose titration are crucial to minimize the risks associated with furosemide use in CKD patients 1.
From the Research
Furosemide Use in CKD
- Furosemide is a commonly used diuretic in the treatment of chronic kidney disease (CKD) patients, primarily for hypertension and fluid overload 2, 3, 4, 5.
- The use of furosemide in CKD patients has been associated with both beneficial and adverse effects, including changes in blood pressure, fluid compartments, and renal function 2, 4, 5.
- A study found that furosemide use in CKD patients was associated with a decline in extracellular water and a reduction in blood pressure, with the maximum effect observed at higher doses 2.
- However, another study suggested that the use of high doses of furosemide or combination diuretic therapy may be associated with adverse renal outcomes, including a decline in eGFR and progression to renal replacement therapy 2.
Dosage and Administration
- The optimal dosage and administration of furosemide in CKD patients is not well established, but studies suggest that small doses may be effective in increasing urinary volume and sodium excretion 6.
- A study found that the use of 40 mg of furosemide in CKD patients with residual diuresis was associated with an increase in urinary volume and sodium excretion compared to patients who did not use the drug 6.
- The use of furosemide in combination with other diuretics, such as hydrochlorothiazide, may also be effective in achieving blood pressure control and reducing fluid overload 2.
Adverse Effects
- The use of furosemide in CKD patients may be associated with adverse effects, including intravascular volume depletion, azotemia, ototoxicity, hyperlipidemia, acute pancreatitis, hyperkalemia, and acidosis 5.
- Clinicians should be vigilant in monitoring for these adverse effects and adjusting the dose and frequency of furosemide administration accordingly 4, 5.