Can Hydrochlorothiazide (HCTZ) be given in Acute Kidney Injury (AKI)?

From the Guidelines

Hydrochlorothiazide (HCTZ) should generally be avoided in acute kidney injury (AKI) except in cases of volume overload, where its use may be considered under close monitoring. HCTZ is a thiazide diuretic that works by inhibiting sodium reabsorption in the distal tubule of the kidney, which can worsen kidney function in patients with AKI. According to the KDIGO practice guideline on acute kidney injury, diuretics, including thiazides like HCTZ, are not recommended for the treatment of AKI except in the management of volume overload 1. The guideline suggests that diuretics may actually improve outcomes in cases where volume overload complicates AKI 1.

Key considerations in the management of AKI include:

• Treating the underlying cause of the kidney injury
• Maintaining adequate hydration to support renal perfusion
• Adjusting medications that may be nephrotoxic
• Using loop diuretics like furosemide if fluid overload is present, as they have been shown to have a protective effect on mortality in patients with AKI and volume overload 1
• Careful evaluation of kidney function and close monitoring if HCTZ is considered for use in patients with a history of AKI, for conditions like hypertension or edema.

The potential risks of using HCTZ in AKI, such as exacerbating dehydration, causing electrolyte imbalances, and reducing renal perfusion, must be weighed against any potential benefits, particularly in the absence of volume overload 1.

From the FDA Drug Label

In patients with renal disease, plasma concentrations of hydrochlorothiazide are increased and the elimination half-life is prolonged The FDA drug label does not answer the question of whether HCTZ can be given in Acute Kidney Injury (AKI) directly.

• Key Point: The label mentions that hydrochlorothiazide is eliminated primarily by renal pathways and that in patients with renal disease, plasma concentrations are increased and the elimination half-life is prolonged 2.
• Clinical Decision: Due to the lack of direct information, it is uncertain whether HCTZ can be given in AKI. However, considering the information that HCTZ is eliminated primarily by renal pathways, caution should be exercised when administering HCTZ to patients with renal disease, including AKI.

From the Research

Diuretics in Acute Kidney Injury (AKI)

• The use of diuretics in patients with AKI is a complex issue, and the decision to use them should be made on a case-by-case basis 3.
• Loop diuretics, such as furosemide, are commonly used in critically ill patients with volume overload, but their efficacy depends on several factors, including tubular concentration, interaction with albumin, and diuretic resistance 4.
• Thiazide diuretics, such as hydrochlorothiazide (HCTZ), can be used in combination with loop diuretics to overcome diuretic resistance, but their use may be associated with a higher risk of AKI in certain patient populations 5.
• The combination of HCTZ and spironolactone was found to have a higher risk of AKI than other single diuretics or diuretic combinations in a study of hypertensive inpatients 5.

HCTZ Use in AKI

• There is limited evidence specifically addressing the use of HCTZ in patients with AKI.
• However, a study on diuretics associated AKI found that the combination of diuretics with other drugs, such as antibiotics, contrast media, ACEI, or NSAIDs, can synergistically induce AKI 6.
• Another study found that chronic kidney disease and poor cardiac function are major risk factors for AKI in hypertensive inpatients using ACEI/ARB + diuretic therapy, which may include HCTZ 5.

Fluid Management in AKI

• Fluid management is an integral part of the care of critically ill patients with AKI, and the goal is to restore hemodynamic stability and vital organ perfusion while avoiding interstitial edema 7.
• Isotonic crystalloids should be the preferred agents for fluid therapy in AKI patients, and balanced solutions may reduce the risk of hyperchloremic acidosis and kidney injury 7.
• Accurate assessment of intravascular volume status and response to fluid replacement is crucial in managing AKI patients 7.