Loop diuretics in the management of acute renal failure

a systematic review and meta-analysis.

Sean M. Bagshaw, Anthony Delaney, Michael Haase, William A. Ghali, Rinaldo Bellomo

Research output: Contribution to journalReview ArticleResearchpeer-review

143 Citations (Scopus)

Abstract

BACKGROUND: Loop diuretics are commonly used in critically ill patients with acute renal failure (ARF), but their effect on clinical outcome remains uncertain. We systematically reviewed the literature comparing loop diuretics with control in the management of ARF. METHODS: Studies were identified by search of MEDLINE, EMBASE, and the Cochrane Controlled Clinical Trials Register, and review of proceedings from selected scientific meetings and clinical trial registries, and bibliographies of retrieved citations. We selected randomised controlled trials (RCTs) comparing loop diuretics with control in patients with ARF. Data were extracted in duplicate by two independent reviewers on study characteristics, quality and outcomes. Primary outcomes were mortality, need for renal replacement therapy (RRT) and renal recovery. Secondary outcomes were change to urine output, serum potassium level and acid-base status, duration of ARF or RRT, length of hospital stay and toxicity. RESULTS: Of 62 studies reviewed, five RCTs, enrolling 555 patients, were eligible and analysed. These trials enrolled a mix of patients, but only two included critically ill patients. Overall trial quality was low. There was no statistical difference in mortality (odds ratio [OR], 1.28; 95% CI, 0.89-1.84; P=0.18) or renal recovery (OR, 0.88; 95% CI, 0.59-1.31; P=0.5) with use of loop diuretics compared with control. However, loop diuretics were associated with a shorter duration of RRT (weighted mean difference, ?1.4 days; 95% CI, ?0.2 to ?2.3 days; P=0.02), shorter time to spontaneous decline in serum creatinine level (weighted mean difference, ?2.1 days; 95% CI, ?0.4 to ?3.7 days; P=0.01) and a greater increase in urine output from baseline (OR, 2.6; 95% CI, 1.4-4.9; P=0.004). Insufficient data were available on acid-base status, hospital length of stay or health costs. Four studies reported toxicity, most commonly transient tinnitus and deafness. CONCLUSIONS: Loop diuretics were not associated with improved mortality or rate of independence from RRT, but were associated with shorter duration of RRT and increased urine output. However, these findings have limited relevance to critically ill patients. The relative paucity of high-quality data assessing the value of loop diuretics in ARF for the critically ill suggests a need for a suitably powered randomised trial.

Original languageEnglish
Pages (from-to)60-68
Number of pages9
JournalCritical Care and Resuscitation
Volume9
Issue number1
Publication statusPublished - 1 Jan 2007
Externally publishedYes

Cite this

@article{538983b35d2a446c83de096b3b7eb9d5,
title = "Loop diuretics in the management of acute renal failure: a systematic review and meta-analysis.",
abstract = "BACKGROUND: Loop diuretics are commonly used in critically ill patients with acute renal failure (ARF), but their effect on clinical outcome remains uncertain. We systematically reviewed the literature comparing loop diuretics with control in the management of ARF. METHODS: Studies were identified by search of MEDLINE, EMBASE, and the Cochrane Controlled Clinical Trials Register, and review of proceedings from selected scientific meetings and clinical trial registries, and bibliographies of retrieved citations. We selected randomised controlled trials (RCTs) comparing loop diuretics with control in patients with ARF. Data were extracted in duplicate by two independent reviewers on study characteristics, quality and outcomes. Primary outcomes were mortality, need for renal replacement therapy (RRT) and renal recovery. Secondary outcomes were change to urine output, serum potassium level and acid-base status, duration of ARF or RRT, length of hospital stay and toxicity. RESULTS: Of 62 studies reviewed, five RCTs, enrolling 555 patients, were eligible and analysed. These trials enrolled a mix of patients, but only two included critically ill patients. Overall trial quality was low. There was no statistical difference in mortality (odds ratio [OR], 1.28; 95{\%} CI, 0.89-1.84; P=0.18) or renal recovery (OR, 0.88; 95{\%} CI, 0.59-1.31; P=0.5) with use of loop diuretics compared with control. However, loop diuretics were associated with a shorter duration of RRT (weighted mean difference, ?1.4 days; 95{\%} CI, ?0.2 to ?2.3 days; P=0.02), shorter time to spontaneous decline in serum creatinine level (weighted mean difference, ?2.1 days; 95{\%} CI, ?0.4 to ?3.7 days; P=0.01) and a greater increase in urine output from baseline (OR, 2.6; 95{\%} CI, 1.4-4.9; P=0.004). Insufficient data were available on acid-base status, hospital length of stay or health costs. Four studies reported toxicity, most commonly transient tinnitus and deafness. CONCLUSIONS: Loop diuretics were not associated with improved mortality or rate of independence from RRT, but were associated with shorter duration of RRT and increased urine output. However, these findings have limited relevance to critically ill patients. The relative paucity of high-quality data assessing the value of loop diuretics in ARF for the critically ill suggests a need for a suitably powered randomised trial.",
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Loop diuretics in the management of acute renal failure : a systematic review and meta-analysis. / Bagshaw, Sean M.; Delaney, Anthony; Haase, Michael; Ghali, William A.; Bellomo, Rinaldo.

In: Critical Care and Resuscitation, Vol. 9, No. 1, 01.01.2007, p. 60-68.

Research output: Contribution to journalReview ArticleResearchpeer-review

TY - JOUR

T1 - Loop diuretics in the management of acute renal failure

T2 - a systematic review and meta-analysis.

AU - Bagshaw, Sean M.

AU - Delaney, Anthony

AU - Haase, Michael

AU - Ghali, William A.

AU - Bellomo, Rinaldo

PY - 2007/1/1

Y1 - 2007/1/1

N2 - BACKGROUND: Loop diuretics are commonly used in critically ill patients with acute renal failure (ARF), but their effect on clinical outcome remains uncertain. We systematically reviewed the literature comparing loop diuretics with control in the management of ARF. METHODS: Studies were identified by search of MEDLINE, EMBASE, and the Cochrane Controlled Clinical Trials Register, and review of proceedings from selected scientific meetings and clinical trial registries, and bibliographies of retrieved citations. We selected randomised controlled trials (RCTs) comparing loop diuretics with control in patients with ARF. Data were extracted in duplicate by two independent reviewers on study characteristics, quality and outcomes. Primary outcomes were mortality, need for renal replacement therapy (RRT) and renal recovery. Secondary outcomes were change to urine output, serum potassium level and acid-base status, duration of ARF or RRT, length of hospital stay and toxicity. RESULTS: Of 62 studies reviewed, five RCTs, enrolling 555 patients, were eligible and analysed. These trials enrolled a mix of patients, but only two included critically ill patients. Overall trial quality was low. There was no statistical difference in mortality (odds ratio [OR], 1.28; 95% CI, 0.89-1.84; P=0.18) or renal recovery (OR, 0.88; 95% CI, 0.59-1.31; P=0.5) with use of loop diuretics compared with control. However, loop diuretics were associated with a shorter duration of RRT (weighted mean difference, ?1.4 days; 95% CI, ?0.2 to ?2.3 days; P=0.02), shorter time to spontaneous decline in serum creatinine level (weighted mean difference, ?2.1 days; 95% CI, ?0.4 to ?3.7 days; P=0.01) and a greater increase in urine output from baseline (OR, 2.6; 95% CI, 1.4-4.9; P=0.004). Insufficient data were available on acid-base status, hospital length of stay or health costs. Four studies reported toxicity, most commonly transient tinnitus and deafness. CONCLUSIONS: Loop diuretics were not associated with improved mortality or rate of independence from RRT, but were associated with shorter duration of RRT and increased urine output. However, these findings have limited relevance to critically ill patients. The relative paucity of high-quality data assessing the value of loop diuretics in ARF for the critically ill suggests a need for a suitably powered randomised trial.

AB - BACKGROUND: Loop diuretics are commonly used in critically ill patients with acute renal failure (ARF), but their effect on clinical outcome remains uncertain. We systematically reviewed the literature comparing loop diuretics with control in the management of ARF. METHODS: Studies were identified by search of MEDLINE, EMBASE, and the Cochrane Controlled Clinical Trials Register, and review of proceedings from selected scientific meetings and clinical trial registries, and bibliographies of retrieved citations. We selected randomised controlled trials (RCTs) comparing loop diuretics with control in patients with ARF. Data were extracted in duplicate by two independent reviewers on study characteristics, quality and outcomes. Primary outcomes were mortality, need for renal replacement therapy (RRT) and renal recovery. Secondary outcomes were change to urine output, serum potassium level and acid-base status, duration of ARF or RRT, length of hospital stay and toxicity. RESULTS: Of 62 studies reviewed, five RCTs, enrolling 555 patients, were eligible and analysed. These trials enrolled a mix of patients, but only two included critically ill patients. Overall trial quality was low. There was no statistical difference in mortality (odds ratio [OR], 1.28; 95% CI, 0.89-1.84; P=0.18) or renal recovery (OR, 0.88; 95% CI, 0.59-1.31; P=0.5) with use of loop diuretics compared with control. However, loop diuretics were associated with a shorter duration of RRT (weighted mean difference, ?1.4 days; 95% CI, ?0.2 to ?2.3 days; P=0.02), shorter time to spontaneous decline in serum creatinine level (weighted mean difference, ?2.1 days; 95% CI, ?0.4 to ?3.7 days; P=0.01) and a greater increase in urine output from baseline (OR, 2.6; 95% CI, 1.4-4.9; P=0.004). Insufficient data were available on acid-base status, hospital length of stay or health costs. Four studies reported toxicity, most commonly transient tinnitus and deafness. CONCLUSIONS: Loop diuretics were not associated with improved mortality or rate of independence from RRT, but were associated with shorter duration of RRT and increased urine output. However, these findings have limited relevance to critically ill patients. The relative paucity of high-quality data assessing the value of loop diuretics in ARF for the critically ill suggests a need for a suitably powered randomised trial.

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