New Insights Into Diuretic Use to Treat Congestion in the ICU: Beyond Furosemide

Abstract

Diuretics are commonly used in critically ill patients with acute kidney injury (AKI) and fluid overload in intensive care units (ICU), furosemide being the diuretic of choice in more than 90% of the cases. Current evidence shows that other diuretics with distinct mechanisms of action could be used with good results in patients with selected profiles. From acetazolamide to tolvaptan, we will discuss recent studies and highlight how specific diuretic mechanisms could help to manage different ICU problems, such as loop diuretic resistance, hypernatremia, hyponatremia, or metabolic alkalosis. The current review tries to shed some light on the potential use of non-loop diuretics based on patient profile and give recommendations for loop diuretic treatment performance focused on what the intensivist and critical care nephrologist need to know based on the current evidence.

Sodium and potassium changes during decongestion with acetazolamide – A pre‐specified analysis from the ADVOR trial

“…4 Adding acetazolamide elegantly fits in this pathophysiology, especially in the case of prolonged loop diuretic administration because the latter prevents renal medullar osmotic build-up which reduces concentrating ability in the collecting ducts even more. 4,25 There was a non-significant trend toward lower baseline sodium levels in the acetazolamide arm, which was no longer present during follow-up, which might be explained by the fact that acetazolamide might facilitate the ability of the kidneys to excrete free water to help correct dilutional hyponatraemia. Finally, despite the comorbid AHF population in the ADVOR trial, we did not observe any significant treatment effect modification or harm of acetazolamide according to baseline serum and potassium categories, both in covariate adjusted and unadjusted analysis.…”

“…To antagonize these detrimental effects in order to improve free water excretion, one should try to facilitate solute flow in the distal parts so that the distal nephron can dilute urine to an osmolality as low as 10‐fold of serum 4 . Adding acetazolamide elegantly fits in this pathophysiology, especially in the case of prolonged loop diuretic administration because the latter prevents renal medullar osmotic build‐up which reduces concentrating ability in the collecting ducts even more 4,25 . There was a non‐significant trend toward lower baseline sodium levels in the acetazolamide arm, which was no longer present during follow‐up, which might be explained by the fact that acetazolamide might facilitate the ability of the kidneys to excrete free water to help correct dilutional hyponatraemia.…”

Якому Петльовому Діуретику Надати Перевагу: Огляд Даних Доказової Медицини

“…Незважаючи на наведені статистичні дані, протягом останніх років усе частіше лунають заклики щодо зміни розповсюдженої парадигми застосування фуросеміду й переходу до активного клінічного застосування торасеміду [5,6]. Такі думки, як правило, ґрунтуються на фармакологічних особ ливостях цих петльових діуретиків та даних доказової медицини.…”

“…Терапія торасемідом має додаткові переваги, які описані відносно нещодавно; одна з них полягає у здатності препарату інгібувати ренін-ангіотензин-альдостеронову систему (РААС). Переконливо доведено, що перебіг СН Рисунок 1 Будова нефрону та зони дії діуретиків [6] асоційований із активацією РААС: трансформацією ангіотензиногену в ангіотензин I, ангіотензин II за допомогою ангіотензинперетворювального ферменту [8]. Впливаючи на рецептор ангіотензину I, ангіотензин II сприяє зростанню синтезу та секреції альдостерону, атерогенезу, проліферації ендотеліальних гладких м'язових клітин, звуженню судин, пригніченню апоптозу, підвищенню активності оксидативного стресу.…”

Alcoholic Extracts of Eleusine indica as Alternative Diuretic Regimens: A Computational Based Investigation

“…Furthermore, a medical chemistry approach converted sulphanilamide to chlorothiazide (Diuril) by modifying the sulfamoyl and amino groups, resulting in improved saluretic effects with minimal or no increase in urinary bicarbonate excretion (Cheng et al, 2017;Zhao and Cao, 2022). In 1962, researchers transformed the sulphonamide moiety into furosemide, which emerged as the most potent diuretic in clinical practice to date (Sica et al, 2011;Escudero et al, 2022). However, several side effects such as blurred vision, loss of appetite, itching, stomach upset, headache, and weakness necessitate the need for naturalderived potential agents to replace these synthetic candidates.…”