Abstract
Diuretics are agents commonly used in diseases characterized by excess extracellular fluid, including chronic kidney disease, the nephrotic syndrome, cirrhosis and heart failure. Multiple diuretic classes, including thiazide-type diuretics, loop diuretics and K+-sparing diuretics, are used to treat patients with these diseases, either individually or as combination therapies. An understanding of what determines a patient's response to a diuretic is a prerequisite to the correct use of these drugs. The response of patients with these diseases to diuretics, which is related to the dose, is best described by a sigmoid curve whose contour can become distorted by any of the several sodium-retaining states that are directly or indirectly associated with renal disease. Diuretic actions are of considerable importance to patients who have renal disease, as their effective use assists in extracellular fluid volume control, reducing excretion of protein in urine and lessening the risk of developing hyperkalemia. Diuretic-related adverse events that involve the uric acid, Na+ and K+ axes are not uncommon; therefore the clinician must be vigilant in looking for biochemical disturbances. As a result of diuretic-related adverse events, clinicians must be resourceful in the dose amount and frequency of dosing.
Key Points
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Diuretic therapy is mainly used in renal disease to facilitate extracellular fluid volume control, lessen the tendency to develop hyperkalemia and lower blood pressure
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The response to a loop diuretic is optimized by a clinically relevant time course of urinary drug delivery; a number of aspects of renal failure alter this relationship
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Although thiazide-type diuretics can elicit a response in patients with a glomerular filtration rate <50 ml/min/1.73 m2, loop diuretics are generally the diuretic of choice in patients with renal insufficiency
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K+-sparing diuretics should be used cautiously in patients with chronic kidney disease
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In patients with end-stage renal disease who have some residual renal function, treatment with a loop diuretic can be a useful adjunct therapy to lessen interdialytic fluid restriction
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Diuretic-related adverse events are typically dose-dependent and can be a particular problem when high diuretic doses are necessary to control excess extracellular fluid volume
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Sica, D. Diuretic use in renal disease. Nat Rev Nephrol 8, 100–109 (2012). https://doi.org/10.1038/nrneph.2011.175
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DOI: https://doi.org/10.1038/nrneph.2011.175
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