The effect of low-dose furosemide in critically ill patients with early acute kidney injury: A pilot randomized blinded controlled trial (the SPARK study)

Bagshaw, Sean M.; Gibney, R. T. Noel; Krüger, Peter; Hassan, Imran; McAlister, Finlay A.; Bellomo, Rinaldo

doi:10.1016/j.jcrc.2017.07.030

Cited by 58 publications

(64 citation statements)

References 43 publications

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“…In regard to rates of hypernatremia, providers were permitted to request continuation of furosemide despite elevated sodium levels, likely resulting in the subsequent increased rate of metolazone use in the intervention group. There was a significant difference in cumulative fluid balance that was likely due to higher furosemide exposure in the intervention group, as demonstrated in previous protocols of furosemide in acute kidney injury [10]. The significant increase in episodes of hypernatremia and hypokalemia are predictable and reversible within this strategy.…”

Section: Discussionmentioning

confidence: 60%

“…Previous protocols guiding volume removal in the critically ill can be found in specific populations including acute decompensated heart failure, AKI, or RRT weaning, with protocolized approaches often improving clinical outcomes versus standard of care [9][10][11]. Further, while limited evidence is available steering diuretic deresuscitation in the broad ICU population, protocols have relied upon dated monitoring parameters, including central venous or pulmonary artery occlusion pressures [12][13][14].…”

Section: Introductionmentioning

confidence: 99%

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Impact of protocolized diuresis for de-resuscitation in the intensive care unit

et al. 2020

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Objective: Administration of diuretics has been shown to assist fluid management and improve clinical outcomes in the critically ill post-shock resolution. Current guidelines have not yet included standardization or guidance for diuretic-based de-resuscitation in critically ill patients. This study aimed to evaluate the impact of a multi-disciplinary protocol for diuresis-guided de-resuscitation in the critically ill. Methods: This was a pre-post single-center pilot study within the medical intensive care unit (ICU) of a large academic medical center. Adult patients admitted to the Medical ICU receiving mechanical ventilation with either (1) clinical signs of volume overload via chest radiography or physical exam or (2) any cumulative fluid balance ≥ 0 mL since hospital admission were eligible for inclusion. Patients received diuresis per clinician discretion for a 2-year period (historical control) followed by a diuresis protocol for 1 year (intervention). Patients within the intervention group were matched in a 1:3 ratio with those from the historical cohort who met the study inclusion and exclusion criteria. Results: A total of 364 patients were included, 91 in the protocol group and 273 receiving standard care. Protocolized diuresis was associated with a significant decrease in 72-h post-shock cumulative fluid balance [median, IQR − 2257 (− 5676-920) mL vs 265 (− 2283-3025) mL; p < 0.0001]. In-hospital mortality in the intervention group was lower compared to the historical group (5.5% vs 16.1%; p = 0.008) and higher ICU-free days (p = 0.03). However, no statistically significant difference was found in ventilator-free days, and increased rates of hypernatremia and hypokalemia were demonstrated. Conclusions: This study showed that a protocol for diuresis for de-resuscitation can significantly improve 72-h post-shock fluid balance with potential benefit on clinical outcomes.

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Section: Discussionmentioning

confidence: 60%

Section: Introductionmentioning

confidence: 99%

Impact of protocolized diuresis for de-resuscitation in the intensive care unit

et al. 2020

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“…Current guideline recommends defining AKI based on serum creatinine (SCr) increase and oliguria, and staging AKI by the worse of the two parameters [7]. To explore the effect of diuretics on outcomes of AKI, studies often included patients using both UO and SCr criteria [2,8]. However, Kellum and colleagues in a study of 23,866 AKI patients found that the mortality of patients with AKI defined by UO criteria was much lower than those staged according to both UO and SCr criteria [9].…”

Section: Introductionmentioning

confidence: 99%

Association between furosemide administration and outcomes in critically ill patients with acute kidney injury

Zhao

Ying

et al. 2020

Crit Care

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Background: Although current guidelines for AKI suggested against the use of furosemide in AKI management, the effect of furosemide on outcomes in real-world clinical settings remains uncertain. The aim of the present study was to investigate the association between furosemide administration and outcomes in critically ill patients with AKI using real-world data. Methods: Critically ill patients with AKI were identified from the Medical Information Mart for Intensive Care (MIMIC)-III database. Propensity score (PS) matched analysis was used to match patients receiving furosemide to those without diuretics treatment. Linear regression, logistic regression model, and Cox proportional hazards model were used to assess the associations between furosemide and length of stay, recovery of renal function, and inhospital and 90-day mortality, respectively. Results: A total of 14,154 AKI patients were included in the data analysis. After PS matching, 4427 pairs of patients were matched between the patients who received furosemide and those without diuretics treatment. Furosemide was associated with reduced in-hospital mortality [hazard ratio (HR) 0.67; 95% CI 0.61-0.74; P < 0.001] and 90-day mortality [HR 0.69; 95% CI 0.64-0.75; P < 0.001], and it was also associated with the recovery of renal function [HR 1.44; 95% CI 1.31-1.57; P < 0.001] in overall AKI patients. Nevertheless, results illustrated that 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 (A-on-C) renal injury. Conclusions: Furosemide administration was associated with improved short-term survival and recovery of renal function in critically ill patients with AKI. Furosemide was especially effective in patients with AKI UO stage 2-3 degree. However, it was not effective in those with AKI SCr stage 2-3 and chronic kidney disease. The results need to be verified in randomized controlled trials.

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“…In fact, automated matched hydration systems using diuretics and fluids together exist for the prevention of contrast-associated AKI (CA-AKI). While some authors found a reduction in the incidence of CA-AKI [5], studies in patients with AKI did not demonstrate a beneficial effect on progression of AKI [6]. In general, fluids should be considered as therapy for patients with intravascular hypovolaemia and diuretics should be reserved for patients with intravascular hypervolaemia.…”

Section: Myth #1mentioning

confidence: 98%

“…However, frusemide has no direct effect on chances of renal recovery. A pilot trial (the SPARK study) compared low-dose frusemide versus placebo in patients with early AKI and found no difference in the rate of worsening AKI or need for RRT [6].…”

Section: Myth #7mentioning

confidence: 99%