Effect of continuous furosemide infusion on outcome of acute kidney injury

Case report: Resolution of oligo-anuric acute kidney injury with furosemide administration in a cat following lily toxicity

Objective

To describe the successful outcome of a case of oligo-anuric acute kidney injury in a cat secondary to lily ingestion.

Case summary

A 12-week-old intact male domestic short-hair cat weighing 1.64 kg (3.6 lb) presented with a 12-h duration of vomiting and lethargy after exposure to lilies of the genera Lilium species 24 h prior to presentation. Severe azotemia (Creatinine 5.8 mg/dL, BUN > 100 mg/dL) and hyperkalemia (9.36 mmol/L) were noted on the day of presentation. Treatment of hyperkalemia was instituted with calcium gluconate, lactated ringers solution, dextrose, regular short-acting insulin, albuterol, and sodium bicarbonate, Oliguria to anuria was highly suspected based on a lack of urine production 21 h after hospitalization with intravenous fluid administration and a static bladder size. The cat was administered 4 mg/kg of furosemide, and urinated at 6 h following administration and continued to produce over 6 ml/kg/h of urine in the next 24 h. Two days following furosemide administration, the cat's hyperkalemia and azotemia resolved. The cat was discharged after 4 days of hospitalization, and a recheck revealed no persistent azotemia or hyperkalemia.

Unique information

Anuric acute kidney injury secondary to lily toxicity is associated with a poor prognosis, and the only treatment modality previously described is hemodialysis. The cat in this report was successfully managed with medical intervention and furosemide administration, with complete resolution of the acute kidney injury.

Systematic Review and Meta-Analysis of the Effect of Loop Diuretics on Antibiotic Pharmacokinetics

Loop diuretics and antibiotics are commonly co-prescribed across many clinical care settings. Loop diuretics may alter antibiotic pharmacokinetics (PK) via several potential drug interactions. A systematic review of the literature was performed to investigate the impact of loop diuretics on antibiotic PK. The primary outcome metric was the ratio of means (ROM) of antibiotic PK parameters such as area under the curve (AUC) and volume of distribution (V_d) on and off loop diuretics. Twelve crossover studies were amenable for metanalysis. Coadministration of diuretics was associated with a mean 17% increase in plasma antibiotic AUC (ROM 1.17, 95% CI 1.09-1.25, I² = 0%) and a mean decrease in antibiotic V_d by 11% (ROM 0.89, 95% CI 0.81-0.97, I² = 0%). However, the half-life was not significantly different (ROM 1.06, 95% CI 0.99-1.13, I² = 26%). The remaining 13 observational and population PK studies were heterogeneous in design and population, as well as prone to bias. No large trends were collectively observed in these studies. There is currently not enough evidence to support antibiotic dosing changes based on the presence or absence of loop diuretics alone. Further studies designed and powered to detect the effect of loop diuretics on antibiotic PK are warranted in applicable patient populations.

Continuous versus intermittent use of furosemide in patients with heart failure and moderate chronic renal dysfunction

Aims

There is paucity of clinical data comparing continuous infusion (CI) with bolus injection (BI) of intravenous loop diuretics in patients with acute decompensated heart failure (ADHF) and chronic renal dysfunction. This study aimed to compare the efficacy and safety of CI versus BI intravenous furosemide administration in patients with ADHF and moderate chronic renal insufficiency.

Methods and results

Acute decompensated heart failure and moderate chronic renal insufficiency [with estimated glomerular filtration rate (eGFR) 15.0–44.9 mL/min/1.73 m²] were randomized to start intravenous furosemide by BI or by a 6 h CI. End points included freedom from congestion at 72 h, the degree of dyspnoea assessed using the 0–10 Borg's category ratio scale, net daily urine output, weight loss during the study, length of hospital stay, total urinary sodium excretion, and development of acute kidney injury or electrolyte disturbance. After 72 h of treatment, the rate of the primary endpoint of freedom from congestion in the CI group was significantly higher than that in the BI group (69.05% vs. 43.59%, P = 0.02). The modified Borg scale indicated patients in the CI group had lower dyspnoea score than those in the BI group at 48 h (4.29 ± 1.23 vs. 5.97 ± 1.56; P = 0.02) and 72 h (1.15 ± 0.35 vs. 2.66 ± 0.83; P = 0.003). There were other significant differences favouring the CI group with regard to net urine output at 72 h (5145.98 ± 621.37 mL vs. 3755.95 ± 456.93 mL; P = 0.007), the mean body weight loss (4.72 ± 1.01 kg vs. 3.53 ± 0.73 kg; P = 0.02) and the total urinary sodium excretion (385.05 ± 38.15 vs. 320.33 ± 37.67; P = 0.02). The length of hospitalization in the CI group was significantly shorter than that in the BI group (10.36 ± 4.20 days vs. 15.68 ± 6.15 days; P = 0.02). No significant differences were observed between groups in the frequency of acute kidney injury, tinnitus, electrolyte disturbance or mortality.

Conclusions

Continuous intravenous infusion of furosemide resulted in significantly greater diuresis than bolus administration of an equal dose in patients with moderate chronic renal insufficiency and ADHF, while no differences emerged in terms of side effects or mortality.

Effect of Combining Furosemide With Standard Hydration Therapy on Contrast-Induced Acute Kidney Injury Following Coronary Angiography or Intervention in a High-Risk Population

This study aimed to investigate whether combining furosemide with standard hydration therapy results in increased preventive effects on contrast-induced acute kidney injury (CI-AKI) following coronary angiography (CA) or percutaneous coronary intervention (PCI). Patients (n = 230) were enrolled in the study and were randomized to the furosemide group or the control group. Patients in the furosemide group received 0.2 to 0.5 mg/kg of furosemide as a continuous intravenous infusion for 24 hours postoperatively and the same standard hydration regimen received by the control group. Blood samples were obtained 24 hours before and 48 hours after the procedure and urine volume was recorded postprocedure. Patients were followed up for an average of 6 months after the procedure. The incidence of CI-AKI in the furosemide group was significantly lower than that in the control group (8.7% vs 18.3%, P = .034). Multivariate logistic regression showed that age-glomerular filtration rate-ejection fraction score and V/estimated glomerular filtration rate ratio were independent risk factors for CI-AKI. During the average 6-month follow-up, incidence of major adverse cardiovascular events (MACEs) in the furosemide group was also significantly lower. Furosemide combined with standard hydration therapy may reduce the incidence of CI-AKI and MACEs following CA or PCI.