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Mehta RL, Pascual MT, Soroko S, Chertow GM, for the PICARD Study Group. Diuretics, Mortality, and Nonrecovery of Renal Function in Acute Renal Failure. JAMA. 2002;288(20):2547–2553. doi:10.1001/jama.288.20.2547
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).
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
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.
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