Should torsemide be avoided in patients with Chronic Kidney Disease (CKD) stage 4, also known as Severe Impaired Renal Function?

From the Guidelines

Torsemide should not be avoided in CKD stage 4, but rather used cautiously with careful monitoring of the patient's response, electrolytes, and kidney function. When prescribing torsemide in advanced kidney disease, it is recommended to start with lower doses (typically 5-10 mg daily) and adjust as necessary based on clinical response 1. Torsemide has advantages over other loop diuretics in CKD patients, including better oral bioavailability and more predictable absorption compared to furosemide, which can be beneficial when gut edema is present. Additionally, torsemide has a longer half-life, allowing for once-daily dosing in most cases.

Key Considerations

• Regular monitoring of electrolytes (particularly potassium, sodium, and magnesium), blood pressure, and kidney function is essential when using any loop diuretic in advanced CKD 1.
• The effects of loop diuretics on renal function are well documented, and current guidelines emphasize the importance of renal function monitoring, suggesting no more than 2 weeks between initiation and first follow-up test 1.
• Slow titration is recommended at 2-week intervals with close follow-up after dose changes to facilitate detection of a sudden fall in renal function after drug initiation or a progressive deterioration with dose increments 1.

Monitoring and Dose Adjustments

• Monitoring should include serum creatinine, electrolytes, and blood pressure, with adjustments made as necessary to minimize the risk of adverse effects 1.
• The maximum daily dose of torsemide is 200 mg, with a duration of action of 12-16 hours 1.
• It is crucial to balance the benefits of torsemide with the potential risks, particularly in patients with advanced CKD, and to carefully monitor patients for signs of worsening kidney function or other adverse effects 1.

From the FDA Drug Label

In patients with renal failure, renal clearance of torsemide is markedly decreased but total plasma clearance is not significantly altered. A smaller fraction of the administered dose is delivered to the intraluminal site of action, and the natriuretic action of any given dose of diuretic is reduced

• Renal Impairment: The drug label mentions that in patients with renal failure, the renal clearance of torsemide is decreased, but it does not explicitly state that torsemide should be avoided in CKD 4.
• Key Consideration: The label does indicate that the natriuretic action of torsemide is reduced in patients with renal failure, which may be a consideration in CKD 4 patients.
• Clinical Decision: Based on the available information, it is unclear whether torsemide should be avoided in CKD 4 patients, as the label does not provide a direct answer to this question 2.

From the Research

Diuretic Therapy in CKD

• The provided studies do not directly address whether torsemide should be avoided in CKD 4 patients 3, 4, 5, 6, 7.
• However, studies have shown that diuretic therapy can be effective in managing fluid overload in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) 6, 7.
• Combination therapy with low-dose metolazone and furosemide has been shown to be effective in managing refractory fluid overload in elderly renal failure patients under palliative care 7.
• The use of diuretics in CKD patients should be carefully monitored to avoid adverse effects such as serum electrolyte losses and hyperuricemia 3.

Exercise and CKD

• Exercise training has been shown to have health benefits for patients with CKD, including improved physical function and possibly slower decline in kidney function 4, 5.
• Aerobic exercise interventions have been shown to increase maximal oxygen consumption and improve blood pressure control, lipid profiles, and mental health in CKD patients 4.
• Resistance exercise training can increase muscle strength and size and improve functioning in CKD patients 4, 5.

Diuretic Therapy in ESRD

• The combination of furosemide, hydrochlorothiazide, and spironolactone has been shown to result in higher urine output and better volume control compared to furosemide alone in ESRD patients on continuous ambulatory peritoneal dialysis (CAPD) 6.