Can diuretics cause Acute Kidney Injury (AKI)?

From the Guidelines

Diuretics can cause acute kidney injury (AKI), particularly when used in patients who are already dehydrated or have underlying kidney disease, and their use should be carefully considered and monitored. The most recent and highest quality study, 1, suggests that diuretics should not be used to treat AKI, except in the management of volume overload. This is because diuretics can lead to volume depletion, reducing blood flow to the kidneys, and may also cause interstitial nephritis or hyperkalemia, which can worsen kidney function.

Key Considerations

• Diuretics like furosemide (Lasix), hydrochlorothiazide, and spironolactone can lead to AKI through several mechanisms, including volume depletion and interstitial nephritis 1.
• The risk of AKI increases when diuretics are combined with other medications that affect kidney function, such as NSAIDs or ACE inhibitors 1.
• Elderly patients and those with heart failure, cirrhosis, or chronic kidney disease are especially vulnerable to the adverse effects of diuretics on kidney function 1.
• To minimize risk, healthcare providers should start with lower doses, monitor kidney function and electrolytes regularly, ensure adequate hydration, and adjust dosing based on the patient's response and kidney function 1.

Clinical Implications

• The use of diuretics in patients with AKI should be carefully considered and monitored, with a focus on managing volume overload and minimizing the risk of adverse effects on kidney function 1.
• Alternative treatments, such as dialysis, may be necessary in some cases, and the decision to use diuretics should be made on a case-by-case basis, taking into account the individual patient's needs and risk factors 1.

From the FDA Drug Label

5.1 Hypotension and Worsening Renal Function Excessive diuresis may cause potentially symptomatic dehydration, blood volume reduction and hypotension and worsening renal function, including acute renal failure particularly in salt-depleted patients or those taking renin-angiotensin aldosterone inhibitors.

• Yes, diuretics like torsemide can cause Acute Kidney Injury (AKI), particularly in certain patient populations such as those who are salt-depleted or taking renin-angiotensin aldosterone inhibitors 2.
• Key factors that increase the risk of AKI include excessive diuresis, dehydration, and blood volume reduction.
• It is essential to monitor volume status and renal function periodically to minimize the risk of AKI in patients taking torsemide 2.

From the Research

Diuretic Use in Acute Kidney Injury (AKI)

• Diuretics are often prescribed to maintain or increase urine output in patients with AKI, but their effectiveness in improving patient outcomes is debated 3.
• Studies have shown that diuretics, including loop diuretics, are ineffective in reducing mortality, the need for dialysis, or improving renal function in AKI patients 3, 4.
• The use of diuretics, such as furosemide, may be beneficial in managing volume overload and pulmonary edema, but their role in preventing or treating AKI is limited 5, 6.
• Diuretics may even be harmful in certain situations, such as when used in high doses or without proper hydration, leading to hypotension, reduced renal perfusion, and worsening of kidney function 4, 5.

Risks and Benefits of Diuretic Use in AKI

• The risk of AKI may be increased with diuretic use, particularly when used in high doses or without proper hydration 4.
• However, diuretics may be beneficial in certain situations, such as in patients with mild to moderate renal insufficiency, where they may help prevent AKI or reduce the risk of progression to chronic kidney disease (CKD) 3, 5.
• The furosemide stress test may be useful in identifying patients at high risk of AKI progression, but its clinical implications need to be further determined 5.

Clinical Practice and Diuretic Use in AKI

• A multinational survey of clinicians found that diuretics, particularly furosemide, are commonly used in AKI patients, despite uncertainty about their effectiveness 7.
• Clinicians often use diuretics to manage volume overload and pulmonary edema, but may not believe they can reduce mortality or improve renal recovery 7.
• There is a need for higher-quality evidence on diuretic use in AKI, and many clinicians are willing to participate in randomized controlled trials to determine the effectiveness of diuretics in this setting 7.