Diuretics, Mortality, and Nonrecovery of Renal Function in Acute Renal Failure | Acute Kidney Injury | JAMA | JAMA Network
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Klahr S, Miller SB. Acute oliguria.  N Engl J Med.1998;338:671-675.Google Scholar
Sladen RN. Oliguria in the ICU: systematic approach to diagnosis and treatment.  Anesthesiol Clin North America.2000;18:739-752, viii.Google Scholar
Bellomo R, Ronco C. Indications and criteria for initiating renal replacement therapy in the intensive care unit.  Kidney Int Suppl.1998;66:S106-S109.Google Scholar
Wilson WC, Aronson S. Oliguria: a sign of renal success or impending renal failure?  Anesthesiol Clin North America.2001;19:841-883.Google Scholar
Anderson RJ, Linas SL, Berns AS.  et al.  Nonoliguric acute renal failure.  N Engl J Med.1977;296:1134-1138.Google Scholar
Diamond JR, Yoburn DC. Nonoliguric acute renal failure.  Arch Intern Med.1982;142:1882-1884.Google Scholar
Brown RS. Renal dysfunction in the surgical patient: maintenance of high output state with furosemide.  Crit Care Med.1979;7:63-68.Google Scholar
Gerlach AT, Pickworth KK. Contrast medium-induced nephrotoxicity: pathophysiology and prevention.  Pharmacotherapy.2000;20:540-548.Google Scholar
Solomon R, Werner C, Mann D, D'Elia J, Silva P. Effects of saline, mannitol, and furosemide to prevent acute decreases in renal function induced by radiocontrast agents.  N Engl J Med.1994;331:1416-1420.Google Scholar
Weinstein JM, Heyman S, Brezis M. Potential deleterious effect of furosemide in radiocontrast nephropathy.  Nephron.1992;62:413-415.Google Scholar
Davidman M, Olson P, Kohen J, Leither T, Kjellstrand C. Iatrogenic renal disease.  Arch Intern Med.1991;151:1809-1812.Google Scholar
Lassnigg A, Donner E, Grubhofer G, Presterl E, Druml W, Hiesmayr M. Lack of renoprotective effects of dopamine and furosemide during cardiac surgery.  J Am Soc Nephrol.2000;11:97-104.Google Scholar
Visweswaran P, Massin EK, Dubose Jr TD. Mannitol-induced acute renal failure.  J Am Soc Nephrol.1997;8:1028-1033.Google Scholar
Brown CB, Ogg CS, Cameron JS. High dose furosemide in acute renal failure: a controlled trial.  Clin Nephrol.1981;15:90-96.Google Scholar
Kleinknecht D, Ganeval D, Gonzalez-Duque LA, Fermanian J. Furosemide in acute oliguric renal failure: a controlled trial.  Nephron.1976;17:51-58.Google Scholar
Gubern JM, Sancho JJ, Simo J, Sitges-Serra A. A randomized trial on the effect of mannitol on postoperative renal function in patients with obstructive jaundice.  Surgery.1988;103:39-44.Google Scholar
Shilliday IR, Quinn KJ, Allison ME. Loop diuretics in the management of acute renal failure: a prospective, double-blind, placebo-controlled, randomized study.  Nephrol Dial Transplant.1997;12:2592-2596.Google Scholar
Chang RW, Jacobs S, Lee B, Pace N. Predicting deaths among intensive care unit patients.  Crit Care Med.1988;16:34-42.Google Scholar
Mehta RL, McDonald B, Gabbai FB.  et al.  A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure.  Kidney Int.2001;60:1154-1163.Google Scholar
Hanley JA, McNeil BJ. The meaning and use of the area under a receiver operating characteristic (ROC) curve.  Radiology.1982;143:29-36.Google Scholar
Lemeshow S, Hosmer Jr DW. A review of goodness of fit statistics for use in the development of logistic regression models.  Am J Epidemiol.1982;115:92-106.Google Scholar
Rosenbaum PR, Rubin DB. Reducing bias in observational studies using subclassification on the propensity score.  J Am Stat Assoc.1984;79:516-524.Google Scholar
Kaplan E, Meier P. Nonparametric estimation from incomplete observations.  J Am Stat Assoc.1958;53:457-481.Google Scholar
Mehta RL, Pascual MT, Gruta CG, Zhuang S, Chertow GM. Refining predictive models in critically ill patients with acute renal failure.  J Am Soc Nephrol.2002;13:1350-1357.Google Scholar
Kellum JA. Diuretics in acute renal failure: protective or deleterious?  Blood Purif.1997;15:319-322.Google Scholar
Venkataram R, Kellum JA. The role of diuretic agents in the management of acute renal failure.  Contrib Nephrol.2001;(132):158-170.Google Scholar
Kellum JA. The use of diuretics and dopamine in acute renal failure: a systematic review of the evidence.  Crit Care (Lond).1997;1:53-59.Google Scholar
Lewis J, Salem MM, Chertow GM.  et al. for the Anaritide Acute Renal Failure Study Group.  Atrial natriuretic factor in oliguric acute renal failure.  Am J Kidney Dis.2000;36:767-774.Google Scholar
Bullock ML, Umen AJ, Finkelstein M, Keane WF. The assessment of risk factors in 462 patients with acute renal failure.  Am J Kidney Dis.1985;5:97-103.Google Scholar
Liano F, Gallego A, Pascual J.  et al.  Prognosis of acute tubular necrosis: an extended prospectively contrasted study.  Nephron.1993;63:21-31.Google Scholar
McCarthy JT. Prognosis of patients with acute renal failure in the intensive-care unit: a tale of two eras.  Mayo Clin Proc.1996;71:117-126.Google Scholar
Chertow GM, Lazarus JM, Paganini EP.  et al. for the Auriculin Anaritide Acute Renal Failure Study Group.  Predictors of mortality and the provision of dialysis in patients with acute tubular necrosis.  J Am Soc Nephrol.1998;9:692-698.Google Scholar
Liano F, Pascual J. Outcomes in acute renal failure.  Semin Nephrol.1998;18:541-550.Google Scholar
Mehta RL, McDonald B, Gabbai FB.  et al.  Nephrology consultation in acute renal failure: does timing matter?  Am J Med.2002;113:456-461.Google Scholar
Levy EM, Viscoli CM, Horwitz RI. The effect of acute renal failure on mortality: a cohort analysis.  JAMA.1996;275:1489-1494.Google Scholar
Chertow GM, Levy EM, Hammermeister KE, Grover F, Daley J. Independent association between acute renal failure and mortality following cardiac surgery.  Am J Med.1998;104:343-348.Google Scholar
Bates DW, Su L, Yu DT.  et al.  Mortality and costs of acute renal failure associated with amphotericin B therapy.  Clin Infect Dis.2001;32:686-693.Google Scholar
Cantarovich F, Verho MT. A simple prognostic index for patients with acute renal failure requiring dialysis: French multicentric prospective study on furosemide in acute renal failure requiring dialysis.  Ren Fail.1996;18:585-592.Google Scholar
Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J.for the Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group.  Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial.  Lancet.2000;356:2139-2143.Google Scholar
Original Contribution
November 27, 2002

Diuretics, Mortality, and Nonrecovery of Renal Function in Acute Renal Failure

Author Affiliations

Author Affiliations: Division of Nephrology, University of California, San Diego, Medical Center (Dr Mehta and Mss Pascual and Soroko); and Divisions of Nephrology, Moffitt-Long Hospitals and UCSF–Mt Zion Medical Center, University of California, San Francisco (Dr Chertow).

JAMA. 2002;288(20):2547-2553. doi:10.1001/jama.288.20.2547

Context Acute renal failure is associated with high mortality and morbidity. Diuretic agents continue to be used in this setting despite a lack of evidence supporting their benefit.

Objective To determine whether the use of diuretics is associated with adverse or favorable outcomes in critically ill patients with acute renal failure.

Design Cohort study conducted from October 1989 to September 1995.

Patients and Setting A total of 552 patients with acute renal failure in intensive care units at 4 academic medical centers affiliated with the University of California. Patients were categorized by the use of diuretics on the day of nephrology consultation and, in companion analyses, by diuretic use at any time during the first week following consultation.

Main Outcome Measures All-cause hospital mortality, nonrecovery of renal function, and the combined outcome of death or nonrecovery.

Results Diuretics were used in 326 patients (59%) at the time of nephrology consultation. Patients treated with diuretics on or before the day of consultation were older and more likely to have a history of congestive heart failure, nephrotoxic (rather than ischemic or multifactorial) origin of acute renal failure, acute respiratory failure, and lower serum urea nitrogen concentrations. With adjustment for relevant covariates and propensity scores, diuretic use was associated with a significant increase in the risk of death or nonrecovery of renal function (odds ratio, 1.77; 95% confidence interval, 1.14-2.76). The risk was magnified (odds ratio, 3.12; 95% confidence interval, 1.73-5.62) when patients who died within the first week following consultation were excluded. The increased risk was borne largely by patients who were relatively unresponsive to diuretics.

Conclusions The use of diuretics in critically ill patients with acute renal failure was associated with an increased risk of death and nonrecovery of renal function. Although observational data prohibit causal inference, it is unlikely that diuretics afford any material benefit in this clinical setting. In the absence of compelling contradictory data from a randomized, blinded clinical trial, the widespread use of diuretics in critically ill patients with acute renal failure should be discouraged.