Can furosemide (Lasix) be given to a patient with acute kidney injury (AKI) and heart failure?

Can Furosemide Be Given in Acute Kidney Injury?

Yes, furosemide can and should be given to patients with acute kidney injury (AKI) when volume overload is present, but it must NOT be used to treat or prevent the AKI itself—only to manage the fluid overload that complicates it. 1

Primary Indication: Volume Overload Management Only

• Furosemide is indicated specifically for managing volume overload in AKI patients, not for treating or preventing kidney injury. 1
• The KDIGO guidelines explicitly recommend against using diuretics to prevent AKI (Grade 1B) or to treat AKI except when managing volume overload (Grade 2C). 1
• Randomized controlled trials and meta-analyses clearly demonstrate that furosemide does not prevent AKI and may actually increase mortality when used for this purpose. 1
• In hemodynamically stable, volume-overloaded AKI patients, furosemide may actually improve outcomes by managing fluid balance. 1

Critical Pre-Administration Requirements

Before giving furosemide to an AKI patient, you must verify:

• Systolic blood pressure ≥90-100 mmHg to ensure adequate perfusion. 2, 3
• Absence of marked hypovolemia—check for signs like decreased skin turgor, hypotension, or tachycardia. 2
• No severe hyponatremia (sodium <120-125 mmol/L), which is an absolute contraindication. 2, 3
• No anuria—if present, furosemide should not be given. 2, 3
• Hemodynamic stability—the patient must have adequate tissue perfusion. 1

Dosing Strategy in AKI Context

• Start with a lower initial dose of 20 mg IV furosemide for patients with new-onset heart failure or those not on chronic diuretics. 1
• For patients already on chronic diuretic therapy, the initial IV dose should be at least equivalent to their home oral dose. 1
• Consider reducing the dose by 25-50% if AKI is significant. 1
• The FDA label indicates furosemide is appropriate for edema management when rapid diuresis is needed, including in acute pulmonary edema. 4

Essential Monitoring During Treatment

• Hourly urine output monitoring is essential—target >0.5 mL/kg/hour. 1
• Daily renal function assessment (creatinine, BUN) during IV diuretic therapy. 1
• Electrolyte monitoring every 12-24 hours, particularly potassium and sodium. 1, 4
• Daily weights at the same time each day, targeting maximum loss of 0.5 kg/day without peripheral edema or 1.0 kg/day with peripheral edema. 3
• Place a bladder catheter to track hourly urine output and rapidly assess response. 2

When to Stop Immediately

Furosemide must be discontinued if:

• Systolic blood pressure drops <90 mmHg without circulatory support. 2, 3
• Severe hyponatremia develops (sodium <120-125 mmol/L). 2, 3
• Severe hypokalemia occurs (<3 mmol/L). 2
• Anuria develops. 2, 3
• Progressive renal failure worsens despite treatment. 1

Critical Pitfalls to Avoid

• Never use furosemide in hemodynamically unstable AKI patients—it will precipitate volume depletion, hypotension, and further renal hypoperfusion. 1
• Do not combine furosemide with other nephrotoxic medications (aminoglycosides, NSAIDs, cisplatin)—each nephrotoxin increases AKI odds by 53%. 1, 4
• Avoid using furosemide expecting it to improve renal function—the potential benefit in non-volume overloaded AKI patients is outweighed by risks. 1
• In cirrhotic patients with new AKI, withdraw furosemide immediately as first-line management. 1

Special Consideration: Heart Failure with AKI

• In heart failure patients with AKI and volume overload, congestion itself drives mortality and morbidity more than mild renal dysfunction. 2
• The treatment goal is to eliminate all clinical evidence of fluid retention, even if this results in mild-to-moderate decreases in renal function, as long as the patient remains asymptomatic and perfusion is adequate. 2
• Excessive concern about rising creatinine leads to underutilization of diuretics and refractory edema, which worsens outcomes more than mild renal dysfunction. 2
• Data from the Fluid and Catheter Treatment Trial showed that in patients with acute lung injury who developed AKI, higher furosemide doses had a protective effect on mortality when used to manage positive fluid balance. 1

Evidence Quality Note

The strongest evidence comes from KDIGO guidelines (2025) 1 and major cardiology society guidelines (2025-2026) 2, 3, which consistently emphasize that furosemide's role in AKI is limited to volume overload management in hemodynamically stable patients. Research studies support that transient worsening of renal function during aggressive diuresis may not necessarily portend poor prognosis when managing volume overload. 5, 6, 7