Loop Diuretics during AKI

[John Detter]

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At my institution, our physicians like to "jumpstart the kidneys" with loop diuretics in patients with AKI. It always goes something like this:

Baseline Scr 0.7
Day 1: Scr 1.2 hospitalist starts IV Lasix BID
Day 2: Scr 1.9 hospitalist double Lasix dose
Day 3: Scr 2.8 hospitalist starts Lasix drip + consults nephro
Day 4: Scr 3.7 nephro stops Lasix drip, orders a Bumex drip instead thinking it will work

This reasoning just baffles me, and if anything I would think it would just add more insult to the kidneys. Does anyone else have this issue and/or have successfully stopped this practice?

 

[AlwaysContrary]

I learned in school that using loops during AKI is a good thing because it allows perfusion to the kidneys.

 

[Dred Pirate]

this is a complicated issue - there is the thought that you need a higher dose to overcome diuretic resistance that occurs with renal dysfunction. I have had this conversation with nephro and they often tell me - if they force a patient into temporary dialysis- that it is OK, but it is needed to get the proper urine output.

 

[RxPreceptor]

Think like 600+mg Furosemide equivalents

 

[John Detter]

I learned in school that using loops during AKI is a good thing because it allows perfusion to the kidneys.

I don't think this is supported by evidence. I recently started a descent down the rabbit hole, but the current evidence seems to suggest that there is an increase in urine output there is no difference in outcomes, and if anything it can cause harm. Also, KDIGO/KDOQI guidelines specifically recommend against using loops. Any benefits seem to be purely theoretical, and it looks like we're just treating a number (urine output) and treating ourselves instead of the patient.

 

[NITRAS]

Loop diuretics are for volume status, not renal function.

 

[John Detter]

I can buy into the diuretic resistance mechanism and I agree that loop diuretics should be for volume status. The problem is that our docs specifically use it in euvolemic patients in the hopes of restoring renal function and explain to patients they are "jump starting" the kidneys like they are defibrillating a heart in cardiac arrest. Then the patient becomes hypovolemic and now they add IV fluids on top of a Bumex drip during a shortage of both.

 

[lane one]

I can buy into the diuretic resistance mechanism and I agree that loop diuretics should be for volume status. The problem is that our docs specifically use it in euvolemic patients in the hopes of restoring renal function and explain to patients they are "jump starting" the kidneys like they are defibrillating a heart in cardiac arrest. Then the patient becomes hypovolemic and now they add IV fluids on top of a Bumex drip during a shortage of both.

Wait, in euvolemic patients? So what's the cause of the renal dysfunction that they're trying to "cure"????????

 

[Carboxide]

That's stupid.

 

[AlwaysContrary]

Wait, in euvolemic patients? So what's the cause of the renal dysfunction that they're trying to "cure"????????

Yeah that changes everything. I see no reason to using loops in this case.

 

[CetiAlphaFive]

Working with specialists like that convinced me not to pursue PGYs.