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Evidence summaries

Furosemide to Prevent or Treat Acute Renal Failure in Adults

Furosemide may not be effective in the prevention or treatment of acute renal kidney injury in adults. Level of evidence: "C"

In a pilot multi-center randomized blinded placebo-controlled trial adult patients with AKI were randomly allocated to furosemide bolus and infusion (n=37) or 0.9% saline placebo (n=36). Primary endpoint was worsening AKI, defined by the RIFLE criteria. Groups were similar at baseline. No differences were found in the proportion with worsening AKI (43.2% vs. 37.1%, p=0.6), kidney recovery (29.7% vs. 42.9%, p=0.3), or renal replacement therapy (27.0% s. 28.6%, p=0.8). Adverse events, mostly electrolyte abnormalities, were more common in furosemide-treated patients (p<0.001). Protocol deviations were common, due often to supplementary furosemide.

A database analysis 3 matched critically ill patients receiving furosemide to those without diuretics treatment (4427 pairs) in real world settings. Furosemide was associated with reduced in-hospital mortality (hazard ratio 0.67; 95% CI 0.61 to 0.74; P < 0.001) and 90-day mortality (HR 0.69; 95% CI 0.64 to 0.75; P < 0.001), and it was also associated with the recovery of renal function (HR 1.44; 95% CI 1.31 to 1.57; P < 0.001) in over-all AKI patients. Nevertheless, furosemide was not associated with reduced in-hospital mortality in patients with AKI stage 0-1 defined by UO criteria, AKI stage 2-3 according to SCr criteria, and in those with acute-on-chronic renal injury.

A double-blind, placebo-controlled, randomized pilot trial 4 assessed furosemide infusion in early-onset AKI in critically ill children compared to placebo (n=75). The trial was stopped for futility. No significant difference was noted in the progression of AKI to a higher stage between furosemide and placebo groups (10.5% vs. 21.6%; RR 0.49, 95% CI 0.16 to 1.48). There were no differences in 28-day mortality or in the secondary outcomes. No trial-related severe adverse events occurred.

Comment: The quality of evidence is downgraded by study quality (inadequate or unclear allocation concealment in some studies) and by imprecise results (limited study size for each comparison).

References

  • Bagshaw SM, Gibney RTN, Kruger P et al. The effect of low-dose furosemide in critically ill patients with early acute kidney injury: A pilot randomized blinded controlled trial (the SPARK study). J Crit Care 2017;(42):138-146. [PubMed]
  • Zhao GJ, Xu C, Ying JC et al. Association between furosemide administration and outcomes in critically ill patients with acute kidney injury. Crit Care 2020;24(1):75. [PubMed]
  • Abraham S, Rameshkumar R, Chidambaram M et al. Trial of Furosemide to Prevent Acute Kidney Injury in Critically Ill Children: A Double-Blind, Randomized, Controlled Trial. Indian J Pediatr 2021;88(11):1099-1106. [PubMed]

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