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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

Authors

  • 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
Background

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

Methods

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.

Results

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).

Conclusion

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.