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’s the connection between hypertension (HTN) and primary hyperparathyroidism (PHPT)?

The prevalence of HTN in patients with PHPT has generally been shown to be higher than the general population irrespective of age. Because elevated PTH levels have also been reported in some patients with essential HTN, the association of high PTH levels with HTN may not always be causal in nature1.

Parathyroid HTN is characterized by increased total peripheral vascular resistance, possibly related to dysregulation of major endocrine pressor factors (eg, sympathetic nervous system and/or the renin-angiotensin-aldosterone  axis), dysfunction of resistance vessels due to altered vasodilatory response and/or enhanced vascular constriction due to to pressor hormones. Abnormal calcium metabolism at the level of vascular smooth muscle cells may be the final common pathway1.

In a longitudinal prospective cohort study of mostly older white women, history of HTN and use of furosemide were associated with a signficantly higher risk of PHPT2.

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1. Schiff H, Lang SM. Hypertenson secondary to PHPT: cause or coincidence. Int J Endocrinol 2011;2011, Article ID 974647,6 pages,  http://dx.doi.org/10.1155/2011/974647.
2. Vaidya A, Curhan GC, Paik JM, Kronenberg H, Taylor EN. Hypertension antihypertensive medications, and risk of incident primary hyperparathyroidism. J Clin Endocrinol Metabl 2015;100:2396-2404.  https://www.ncbi.nlm.nih.gov/pubmed/25885946

What’s the connection between hypertension (HTN) and primary hyperparathyroidism (PHPT)?