Should I avoid intravenous furosemide for management of ascites in my patient with cirrhosis?

Generally, yes! IV furosemide for treatment of ascites in patients with cirrhosis should be avoided for couple of reasons.

First, in contrast to patients with congestive heart failure in whom the absorption of oral furosemide may be impaired due to bowel wall edema, patients with cirrhosis and ascites appear to absorb oral furosemide efficiently, similarly to that of control patients.1   Another reason for avoiding IV furosemide in this setting is the possibility of a significant drop in the GFR with its attendant rise in BUN and serum creatinine, clinically resembling a picture of hepatorenal syndrome.2

Although the mechanism of the adverse effect of IV furosemide on the renal function of patients with cirrhosis is not totally clear, furosemide-induced vasoconstriction, not intrasvascular volume depletion due to sodium wasting, seems to play an important role.3

Nevertheless, certain situations may necessitate the use of IV furosemide in patients with cirrhosis and ascites, such as in single doses to help identify patients who will be responsive to diuretics, and in patients in need of prompt diuresis such as those with concurrent pulmonary edema. In a somewhat reassuring study, a single dose of 80 mg IV furosemide reliably identified cirrhotic patients with ascites responsive to diuretics, without a significant risk of deteriorating renal function.3

 

References

  1. Sawhney VK, Gregory PB, Swezey SE, et al. Furosemide disposition in cirrhotic patients. Gastroenterology 1981; 81: 1012-16. https://www.ncbi.nlm.nih.gov/pubmed/7286579
  2. Daskalopoulos G, Laffi G, Morgan T, et al. Immediate effects of furosemide on renal hemodynamics in chronic liver disease with ascites. Gastroenterology 1987;92:1859-1863. https://www.ncbi.nlm.nih.gov/pubmed/3569760
  3. Spahr, L., Villeneuve, J., Tran, H. K., & Pomier-Layrargues, G. Furosemide-induced natriuresis as a test to identify cirrhotic patients with refractory ascites. Hepatology 2001;33:28-31. https://www.ncbi.nlm.nih.gov/pubmed/11124817

 

Contributed by Sam Miller, MD, Mass General Hospital, Boston, MA.

 

Should I avoid intravenous furosemide for management of ascites in my patient with cirrhosis?

What are the potential pitfalls in reliance on serum creatinine levels or urine output in sepsis-associated acute kidney injury (SA-AKI)?

Although serum creatinine and urine output are usually easily measured, several limitations in their interpretation in patients suspected of having sepsis and AKI are worth emphasizing1.

First, there is an inherent lag of hours between a drop in glomerular filtration rate (GFR) and a rise in serum creatinine concentration. Second, in critically ill hypotensive patients with sepsis receiving aggressive fluid resuscitation, hemodilution may mask serum creatinine rise and delay the diagnosis of AKI by a day. Third, sepsis itself may reduce muscular production of creatinine, even in the absence of weight loss, as demonstrated in animal studies2.  Fourth, patients receiving diuretics may fail to meet criteria for AKI diagnosis based on reduced urine output alone because of increased urine output.  

Lastly, as renal function deteriorates, the half-life of serum creatinine increases from several hours to several days3, prolonging the time needed to achieve a new steady-state that may be more reflective of the concurrent GFR.

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 References

  1. Godlin M, Murray P, Mehta. Clinical approach to the patient with AKI and sepsis. Semin Nephrol 2015;35:12-22.
  2. Doi K, Yuen PST, Eisner C, et al. Reduced production of creatinine limits its use as marker of kidney injury in sepsis. J Am Soc Nephrol 2009;20:1217-21.
  3. Chiou WL, Hsu FH. Pharmacokinetics of creatinine in man and its implications in the monitoring of renal function and in dosage regimen modifications in patients with renal insufficiency. J Clin Pharmacol. 1975; 15(5-6):427-34.
What are the potential pitfalls in reliance on serum creatinine levels or urine output in sepsis-associated acute kidney injury (SA-AKI)?