Diuretics and mortality in acute renal failure*

Uchino, Shigehiko MD; Doig, Gordon S. PhD; Bellomo, Rinaldo MD; Morimatsu, Hiroshi MD; Morgera, Stanislao MD; Schetz, Miet MD; Tan, Ian MD; Bouman, Catherine MD; Macedo, Ettiene MD; Gibney, Noel MD; Tolwani, Ashita MD; Ronco, Claudio MD; Kellum, John A. MD Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators

Author Information

From the Department of Intensive Care and Department of Medicine, Austin & Repatriation Medical Centre, Melbourne, Australia (SU, RB, HM); Royal North Shore Hospital and Northern Clinical School, University of Sydney, Sydney, Australia (GSD); Department of Nephrology, University Hospital Charité, Berlin, Germany (SM); Dienst Intensieve Geneeskunde, Universitair Ziekenhuis Gasthuisberg, Leuven, Belgium (MS); Intensive Care Unit, Department of Anaesthesia, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China (IT); Adult Intensive Care Unit, Academic Medical Center, Amsterdam, Holland (CB); Nephrology Division, University of São Paulo School of Medicine, São Paulo, Brazil (EM); Division of Critical Care Medicine, University of Alberta, Edmonton, Canada (NG); Department of Medicine, Division of Nephrology, The University of Alabama at Birmingham, Alabama, (AT); Nephrology-Intensive Care, St. Bortolo Hospital, Vicenza, Italy (CR); and Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA (JK).

Supported, in part, by the Austin Hospital Intensive Care Trust Fund.

Critical Care Medicine32(8):p 1669-1677, August 2004. |DOI:10.1097/01.CCM.0000132892.51063.2F

Abstract

Objective:

According to recent research, diuretics may increase mortality in acute renal failure patients. The administration of diuretics in such patients has been discouraged. Our objective was to determine the impact of diuretics on the mortality rate of critically ill patients with acute renal failure.

Design:

Prospective, multiple-center, multinational epidemiologic study.

Setting:

Intensive care units from 54 centers and 23 countries.

Patients:

Patients were 1,743 consecutive patients who either were treated with renal replacement therapy or fulfilled predefined criteria for acute renal failure.

Interventions:

Three distinct multivariate models were developed to assess the relationship between diuretic use and subsequent mortality: a) a propensity score adjusted multivariate model containing terms previously identified to be important predictors of outcome; b) a new propensity score adjusted multivariate model; and c) a multivariate model developed using standard methods, compensating for collinearity.

Measurements and Main Results:

Approximately 70% of patients were treated with diuretics at study inclusion. Mean age was 68 and mean Simplified Acute Physiology Score II was 47. Severe sepsis/septic shock (43.8%), major surgery (39.1), low cardiac output (29.7), and hypovolemia (28.2%) were the most common conditions associated with the development of acute renal failure. Furosemide was the most common diuretic used (98.3%). Combination therapy was used in 98 patients only. In all three models, diuretic use was not associated with a significantly increased risk of mortality.

Conclusions:

Diuretics are commonly prescribed in critically ill patients with acute renal failure, and their use is not associated with higher mortality. There is full equipoise for a randomized controlled trial of diuretics in critically ill patients with renal dysfunction.