“Too often we enjoy the comfort of opinion without the discomfort of thought.” ― John F. Kennedy
The KDIGO guidelines, the UK NICE guidelines and numerous reviews conclude that diuretics are ineffective in the management of AKI.
" Diuretics further complicate the fluid accumulation-mortality association. Once considered a therapy for oliguria, diuretics are clearly ineffective in preventing or treating AKI. Moreover, some observational studies have demonstrated associations between diuretics and death and renal nonrecovery in AKI. Many clinicians thus avoid diuretics in AKI because of concern that they may induce intravascular hypovolemia as well as exacerbate renal dysfunction and electrolyte abnormalities." (Grams et al)
However, when I look at my nephrology practice over the past 25 years, both at Tufts and at the Brigham, I have continued to use diuretics for the management of ischemic AKI. I am not a particularly dogmatic person , but I haven't been swayed by the guidelines largely because the evidence upon which these guideline recommendations are based is flawed, and because I have seen that a trial of high dose diuretics works. When I say "works" diuretics have successfully converted a patient from oliguria to non-oliguria. In the situations I am asked to consult on these patients, the team is often struggling with fluid management. The issue almost never is whether I can use diuretics to prevent the need for renal replacement therapy.
Thus, my indication for high dose diuretic therapy in AKI is to manage fluid overload better by converting patients from oliguric to non-oliguric AKI.
About 2 years ago a post-hoc analysis of a clinical trial was published in CJASN that I would strongly recommend that you remember to cite when someone asks you to justify the use of high dose diuretics in patients with AKI who are volume expanded.
The study by Morgan Grams from Hopkins and colleagues analyzed data from the Fluid and Catheter Treatment Trial (FACTT), a multicenter, randomized controlled trial evaluating a conservative versus liberal fluid-management strategy in 1000 patients with acute lung injury (ALI). The authors looked at a subset of patients (N=306) that developed AKI as defined by Acute Kidney Injury Network (AKIN) stage 1 criteria (a 50% or 0.3 mg/dl increase in serum creatinine from baseline, occurring over 48 hours or less).
The research question was whether there was an association of post-renal injury fluid balance and diuretic use with 60-day mortality in patients who developed AKI. The hypothesis was that positive fluid balance and diuretic therapy after AKI are independently associated with mortality in patients with ALI.
The study concluded: "A positive fluid balance after AKI was strongly associated with mortality. Post-AKI diuretic therapy was associated with 60-day patient survival in FACTT patients with ALI; this effect may be mediated by fluid balance."
The bottom-line is that like many things in medicine one size does not fit all. In patients with AKI who are markedly fluid overloaded - over 10 L fluid gain - there is evidence that supports the use of diuretics.
The KDIGO guidelines, the UK NICE guidelines and numerous reviews conclude that diuretics are ineffective in the management of AKI.
" Diuretics further complicate the fluid accumulation-mortality association. Once considered a therapy for oliguria, diuretics are clearly ineffective in preventing or treating AKI. Moreover, some observational studies have demonstrated associations between diuretics and death and renal nonrecovery in AKI. Many clinicians thus avoid diuretics in AKI because of concern that they may induce intravascular hypovolemia as well as exacerbate renal dysfunction and electrolyte abnormalities." (Grams et al)
However, when I look at my nephrology practice over the past 25 years, both at Tufts and at the Brigham, I have continued to use diuretics for the management of ischemic AKI. I am not a particularly dogmatic person , but I haven't been swayed by the guidelines largely because the evidence upon which these guideline recommendations are based is flawed, and because I have seen that a trial of high dose diuretics works. When I say "works" diuretics have successfully converted a patient from oliguria to non-oliguria. In the situations I am asked to consult on these patients, the team is often struggling with fluid management. The issue almost never is whether I can use diuretics to prevent the need for renal replacement therapy.
Thus, my indication for high dose diuretic therapy in AKI is to manage fluid overload better by converting patients from oliguric to non-oliguric AKI.
About 2 years ago a post-hoc analysis of a clinical trial was published in CJASN that I would strongly recommend that you remember to cite when someone asks you to justify the use of high dose diuretics in patients with AKI who are volume expanded.
The study by Morgan Grams from Hopkins and colleagues analyzed data from the Fluid and Catheter Treatment Trial (FACTT), a multicenter, randomized controlled trial evaluating a conservative versus liberal fluid-management strategy in 1000 patients with acute lung injury (ALI). The authors looked at a subset of patients (N=306) that developed AKI as defined by Acute Kidney Injury Network (AKIN) stage 1 criteria (a 50% or 0.3 mg/dl increase in serum creatinine from baseline, occurring over 48 hours or less).
The research question was whether there was an association of post-renal injury fluid balance and diuretic use with 60-day mortality in patients who developed AKI. The hypothesis was that positive fluid balance and diuretic therapy after AKI are independently associated with mortality in patients with ALI.
The study concluded: "A positive fluid balance after AKI was strongly associated with mortality. Post-AKI diuretic therapy was associated with 60-day patient survival in FACTT patients with ALI; this effect may be mediated by fluid balance."
The bottom-line is that like many things in medicine one size does not fit all. In patients with AKI who are markedly fluid overloaded - over 10 L fluid gain - there is evidence that supports the use of diuretics.
