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Kidney Week

Abstract: PO0268

Addition of High-Dose Furosemide to Norepinephrine During Treatment of Hepatorenal Syndrome Type 1 Augments Diuresis and Does Not Halt Kidney Function Recovery

Session Information

Category: Acute Kidney Injury

  • 102 AKI: Clinical, Outcomes, and Trials


  • Tayebi, Kasra, Ochsner Medical Center - New Orleans, New Orleans, Louisiana, United States
  • Velez, Juan Carlos Q., Ochsner Medical Center - New Orleans, New Orleans, Louisiana, United States

Withdrawal of diuretics is recommended as a first intervention in patients with cirrhosis who present with acute kidney injury (AKI) to eliminate prerenal factors. Moreover, diuretics are considered potential trigger for hepatorenal syndrome type 1 (HRS-1). As a result, diuretics are rarely utilized once the diagnosis of HRS-1 is made due to concerns for aggravating the clinical course. We hypothesized that after a prerenal state is ruled out and HRS-1 is diagnosed and properly treated with a vasoconstrictor, i.e., the mean arterial pressure (MAP) is effectively raised, use of diuretics is safe and effective


We search records of patients hospitalized at Ochsner Medical Center over a 3 year period who received intravenous (IV) furosemide (FURO) while receiving IV norepinephrine (NE) as a vasoconstrictor specifically for treatment of AKI due to HRS-1. We assessed the change in urine output (UOP) and the trajectory of serum creatinine (sCr) values before and after the initiation of NE and before and after the addition of FURO.


A total of 19 patients with HRS-1 received IV FURO [median duration: 2 (1-8) days); median dose: 160 (80-240) mg boluses q6-24 h)] added to IV NE during the study period. Median age was 52 (31-69) years; 89% white race, 53% women, median MELD score 32 (22-41). At the time of initiation of FURO, median sCr was 3.8 (1.7-7.9) mg/dL. Before initiation of any therapy, the median UOP was 275 (10-695) ml/day. NE alone led to a median increase in UOP to 530 (200-2150) ml/day (p=0.013). Addition of FURO to NE induced a subsequent increase in median UOP to 2045 ml/day (p<0.0001), i.e., median gain in UOP of 1605 ml/day. Fifteen (79%) patients treated with NE+FURO [w/median MAP rise 15 (11-24) mmHg] either maintained or improved the sCr trajectory consistent with kidney recovery and not needing dialysis. The magnitude of NE-induced rise in MAP significantly correlated with the average UOP achieved during the days of combined NE+FURO therapy (R=0.48, p=0.03).


In patients with HRS-1 who are adequately treated with NE and achieved an optimal MAP increment, addition of high-dose IV FURO enhances diuresis without negatively affecting recovery of kidney function.