Furosemide Use in Chronic Hemodialysis Patients
Yes, furosemide can be given to hemodialysis patients who maintain residual urine output, and evidence supports its use to preserve volume control and potentially delay anuria. 1, 2
Patient Selection Criteria
Hemodialysis patients are appropriate candidates for furosemide therapy if they produce at least 100 mL of urine daily. 3 More practically, patients reporting "at least 1 cup of urine output per day" represent suitable candidates for trial therapy. 4
Key eligibility requirements before initiating furosemide:
- Systolic blood pressure ≥90-100 mmHg 5
- Serum sodium >125 mmol/L (severe hyponatremia is an absolute contraindication) 5
- Absence of marked hypovolemia 5
- Absence of anuria 5
- Adequate tissue perfusion without signs of cardiogenic shock 5
Evidence for Efficacy in Hemodialysis Patients
Low-dose furosemide (40 mg daily) doubles both urine volume and sodium excretion in hemodialysis patients with residual renal function compared to those not receiving diuretics. 1 In this study, patients on 40 mg furosemide produced 1142 mL/24h versus 453 mL/24h in controls (p=0.008), with sodium excretion of 112 mEq/24h versus 45 mEq/24h (p=0.02). 1
High-dose furosemide (250-2000 mg daily) can be effective in hemodialysis patients with residual function, though response diminishes over time due to progressive renal disease. 2 In a short-term study, 1000 mg twice daily increased 24-hour urine volume by 109%, sodium excretion by 210%, and chloride excretion by 346%. 2 However, during one-year follow-up, the diuretic effect gradually decreased as underlying renal disease progressed. 2
Importantly, only 5% of hemodialysis patients on furosemide developed anuria at one year compared to 22% of controls, though this difference did not reach statistical significance in the available study. 6
Recommended Dosing Strategy
Initial Dosing
Start with furosemide 40 mg orally once daily in the morning for hemodialysis patients with residual urine output. 1 This low dose has proven efficacy and minimizes adverse effects. 1
Dose Escalation Protocol
If inadequate response after 3-7 days:
- Increase to 80 mg daily (40 mg twice daily) 5
- Further escalation to 160 mg daily if needed 5
- For refractory cases with preserved residual function (creatinine clearance 0.6-6.8 mL/min), doses of 250-1000 mg daily may be considered 2
- Maximum studied doses reach 1000-2000 mg daily in divided doses, though such high doses should be reserved for exceptional circumstances 2, 7
The 2022 pilot study used a maximum dose of 320 mg/day with dose titration based on urine output response, finding this approach generally safe and well-tolerated. 4
Route of Administration
Oral administration is strongly preferred in stable hemodialysis patients. 5 The oral route maintains good bioavailability and avoids acute reductions in glomerular filtration rate associated with IV administration. 5
Critical Monitoring Requirements
Baseline Assessment
Before initiating furosemide:
- Measure 24-hour urine volume 1
- Check serum sodium, potassium, magnesium, and creatinine 5
- Verify blood pressure and volume status 5
- Assess for signs of hypovolemia (decreased skin turgor, hypotension, tachycardia) 5
Ongoing Monitoring
During furosemide therapy:
- Check electrolytes (sodium, potassium, magnesium) every 3-7 days initially, then weekly once stable 5
- Monitor 24-hour urine volume at baseline, 6 months, and 12 months 6
- Assess for ototoxicity, particularly at doses >6 mg/kg/day or with rapid IV administration 3, 5
- Monitor for signs of volume depletion 5
The incidence of ototoxicity appears greater with furosemide and torsemide and much less with bumetanide. 3 High doses should not be given for periods longer than 1 week without careful reassessment. 5
Absolute Contraindications and When to Stop
Discontinue furosemide immediately if any of the following develop: 5
- Severe hyponatremia (serum sodium <120-125 mmol/L)
- Severe hypokalemia (<3 mmol/L)
- Systolic blood pressure <90 mmHg
- Anuria
- Marked hypovolemia
- Progressive renal failure beyond expected trajectory
Important Clinical Caveats
The effectiveness of furosemide therapy may not last long in hemodialysis patients, possibly because of further inevitable decline in residual renal function. 3 The one-year study demonstrated gradual decrease in diuretic response over time due to progression of underlying renal disease. 2
Loop diuretics should be used with caution because of the possibility of ototoxicity. 3 Doses above 250 mg must be given by infusion over 4 hours rather than bolus to prevent hearing loss. 5
Avoid combining high-dose furosemide with aminoglycosides, as this dramatically increases ototoxicity risk. 5
Practical Algorithm for Hemodialysis Patients
- Verify eligibility: Urine output ≥100 mL/day, SBP ≥90 mmHg, sodium >125 mmol/L 3, 5
- Start furosemide 40 mg PO once daily in the morning 1
- Monitor response at 3-7 days: Measure 24-hour urine volume and sodium excretion 1
- If inadequate response: Increase to 80 mg daily, then 160 mg daily as needed 5
- For refractory cases with preserved residual function: Consider 250-1000 mg daily in divided doses 2
- Monitor electrolytes every 3-7 days initially, then weekly 5
- Reassess efficacy at 6 and 12 months: Expect gradual decline in response over time 2, 6
- Discontinue if anuria develops or contraindications emerge 5
The goal is to maximize residual urine output and sodium excretion to reduce interdialytic weight gain and potentially delay complete anuria, while carefully monitoring for electrolyte disturbances and ototoxicity. 1, 2, 6