Is diuretic therapy useful for patients with impaired renal function on hemodialysis (HD)?

Diuretics in Hemodialysis Patients: Clinical Utility

Yes, diuretics can be useful in hemodialysis patients who retain residual renal function (RRF), as they help preserve urine output, reduce interdialytic weight gain, lower cardiovascular mortality risk, and may prolong RRF—but they should be discontinued in anuric patients without meaningful residual kidney function.

Key Clinical Benefits in HD Patients with Residual Renal Function

Loop diuretics offer several important advantages for hemodialysis patients who maintain urine output:

• Mortality benefit: Diuretic use is associated with 14% lower cardiac-specific mortality risk (P = 0.03) and 7% lower all-cause mortality risk in HD patients 1

• Preservation of residual renal function: Patients with RRF on diuretic therapy have almost twice the odds of retaining RRF after 1 year compared to those not receiving diuretics 1

• Volume management: Diuretics reduce interdialytic weight gain and lower the odds of hyperkalemia (potassium >6.0 mmol/L) 1

• Reduced ultrafiltration requirements: By maintaining some native kidney sodium and water excretion, diuretics decrease the fluid removal burden during dialysis sessions 2

Loop Diuretics Are the Agents of Choice

Loop diuretics (furosemide, bumetanide, torsemide) are the preferred agents in end-stage renal disease because they maintain efficacy even when renal function is severely impaired 2. Thiazide diuretics lose effectiveness when creatinine clearance falls below 40 mL/min 2.

• Higher doses are required due to pharmacokinetic changes with diminishing renal clearance 3

• Loop diuretics can increase sodium excretion and urine output even with markedly impaired renal function 4

Clinical Decision Algorithm

When to use diuretics in HD patients:

1. Continue diuretics if: Patient has measurable urine output (typically >200-300 mL/day) and evidence of residual renal function 1

2. Discontinue diuretics if: Patient is anuric or has minimal urine output with no meaningful RRF 1

3. Monitor closely for: Dose-related ototoxicity (especially with concomitant aminoglycosides), electrolyte disturbances, and volume depletion 3

Important Caveats and Common Pitfalls

Avoid automatic discontinuation at dialysis initiation: There is substantial variation in facility practices, with diuretic use ranging from 9.2% in the United States to 21.3% in Europe, and use decreasing sharply after dialysis starts 1. This represents a missed opportunity, as many patients retain RRF early in their dialysis course.

Limited benefit in anuric patients: In patients on maintenance dialysis without urine output, the increase in sodium and water excretion is very limited, while high-dose use carries risks including neurologic lesions, cramps, deafness, weakness, and muscle pain 4.

Potassium-sparing diuretics can be used cautiously: Despite theoretical concerns about hyperkalemia, studies suggest these agents can be safely administered with close monitoring in selected patients 3.

Balance blood pressure control: While diuretics help control extracellular volume expansion and hypertension in chronic renal failure, their effectiveness must be weighed against potential complications 4, 5.

The evidence strongly supports continuing loop diuretics in HD patients with preserved urine output, as the benefits for RRF preservation and cardiovascular outcomes outweigh the risks when appropriately dosed and monitored 1.