Möglichkeiten und Grenzen hochdosierter Diuretikatherapie bei hydropischer Niereninsuffizienz

Abstract

Möglichkeiten und Grenzen hochdosierter Diuretik.therapie bei hydropischer Niereninsuffizienz Alle Diuretika verlieren im Endstadium der Niereninsuffizienz ihre Wirksamkeit. Der Wirkungsverlust beruht sowohl auf dem Ausfall von Nephronen als auch auf einer ungenügenden Diuretikasekretion in das Tubuluslumen, die nach Deetjen (14) eine Mitvoraussetzung der salidiuretischen Wirkung ist. Eine weitere Wirkungsabschwächung könnte sich aus einer bereits funktionell und/oder organisch bedingten Hemmung der tubulären Natriumreabsorption am Angriffspunkt des Diuretikums ergeben. Nach angloamerikanischen Untersuchungen soll durch '574 Umek, Czembirek: Erfahrungen mit der Leberszintigraphie Deutsche Medizinische Wochenschrifl

Effects of Large Doses of Furosemide in End-Stage Chronic Renal Failure

“…These results confirm the previous reports in the literature [11,13,17,18,20]. The negative findings of Beroniade [3] and G regory et al [12] may be due to the small dosages of furosemide used (80-360 mg/day).…”

“…This good tolerance may be due to the moderately high dosage used and the oral route of administration. Secondary effects -deafness and gastric upset -have been reported only after dosages exceeding 1 g/day and rapidly administered intravenously [13,15,21], Although furosemide appears to be an efficient and innocuous (at least in short-term periods) adjunct therapy in chronic uremic patients treated by hemodialysis, the use of this potent diuretic drug, despite its remarkable effects on sodium and water excretion, does not allow us to increase the time intervals between dialyses because it is devoid of any beneficial effect on nitrogen excretion [1,2,9,11,12,[14][15][16]. On the contrary, it should be stressed that decreasing the time intervals between dialyses would allow a more liberal dietary intake and a better control of fluid retention in these patients.…”

“…Owing to their relative innocuity, increasing doses have been used in acute [3][4][5][6]9,20] as well as in chronic renal failure [1][2][3]7,9,20], The benefit of furosemide in the terminal stage of renal failure is however controversial. According to some investigators [3,12], diuretic effects are lacking when creatinine clearance is inferior to 5 ml/min while others observed increased water and sodium excretion rates in patients treated by hemodialysis [ 11,13,17,20] or by peritoneal dialysis [18]. This discrepancy is readily explained by the great variations in dosage, route of administration, and duration of treatment and by the lack of unquestion able controls.…”

Pathophysiology and Treatment of Hypertension and Oedema due to Renal Failure

“…In the past, it has often been claimed that diuret ics increase GFR [31]. Observations that inulin clearance was increased by high doses of furosemide are most easily explained as the result of reduced cardiac preload and in creased cardiac output, with the attendant increase in renal perfusion.…”

“…Inulin clearance is unchanged by thiazides in healthy subjects on high salt intake, while a consistent decrease was noted in the same individuals on low salt intake ( fig. 7) [32], Hypovolaemia, documented by increased total protein concentration and packed cell volume, was accompanied by acti vation of the sympathoadrenal system and the RAAS [31]. Conversely, in patients with sta ble chronic renal failure, no change of GFR is seen after administration of high doses of loop diuretics, provided that hypovolaemia and changes in preload are avoided [33].…”