Use Of Furosemide Research Articles

Hypokalemia and hyperkalemia in patients on peritoneal dialysis: incidence and associated factors.

Hypokalemia is a well-described electrolyte disturbance in patients on peritoneal dialysis (PD). Hyperkalemia, however, is still overlooked, although it also represents a risk factor for mortality. Angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers (ACE/ARB), diuretics, and proton pump inhibitor (PPI) can interfere with potassium levels in these patients. This is a retrospective study that evaluated monthly serum potassium in a 5-year period. Serum potassium disturbances were evaluated as time-average and number of hypo- and hyperkalemia episodes per patient. Prescribed medication such as ACE/ARB, diuretics, and omeprazole were recorded. We evaluated 2025 potassium measurements obtained from 146 patients on PD. Serum potassium ranged from 2.5 to 8.3mEq/L with an average of 4.72 ± 0.74mEq/L. Hypokalemia was found in 59 measurements (2.9%) obtained from 35 patients (23.9%) whereas hyperkalemia was demonstrated in 269 (13.3%) measurements obtained from 74 patients (50.7%). Hypokalemia was associated with low albumin (p = 0.022), and omeprazole use (p = 0.024).Black race was aprotector factor (p=0.031). Omeprazole-associated hypokalemia was seen only in non-anuric patients and remained an independent risk factor even after adjustments. Patients who had hyperkalemia were more likely to be anuric (p = 0.001) and in use of furosemide (p = 0.0001). Hyperkalemia and hypokalemia are very frequent in patients on PD and should be closely monitored. Interventional studies should address the impact of discontinuing omeprazole in the levels of potassium.

Anaphylactic shock with intravenous furosemide: a rare undesired effect

Furosemide is a potent diuretic, with structural similarity to sulphonamide antibiotics. Its relative safety profile is one of the reasons to account for its widespread use. We report a rare case of fatal anaphylaxis with intravenous furosemide administered in our critical care settings for pulmonary edema. Chemical similarity of furosemide with sulphonamide antibiotics shares the possibility of similar allergic side effects. Thus, a more careful clinical use of furosemide, especially if administered intravenous should be kept in mind to avoid such catastrophic events.

Association between chronic ACE inhibitor exposure and decreased odds of severe disease in patients with COVID-19.

Objective:Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Renin-angiotensin-aldosterone-system (RAAS) inhibitors may increase the expression of angiotensin-converting enzyme 2, which is the receptor for SARS-CoV-2 Spike protein. The consequences of using angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) during the COVID-19 pandemic are unknown.Methods:A retrospective cohort study aiming to identify the odds of severe disease (defined as either hospitalization of ≥14 days, admission to the intensive care unit, or death) associated with exposure to ACEi or ARB was conducted. Adult patients (age ≥18 years) with COVID-19 admitted to the İstanbul Faculty of Medicine Corona Center between March 9 and May 11, 2020, were included. Chronic users of ACEi, ARB, or other antihypertensive drugs were matched according to age, sex, sick days before hospitalization, comorbidities, smoking, number of antihypertensive regimens, doxazosin use, furosemide use, and serum creatinine level. Odds ratios (OR) of having severe disease were calculated.Results:In total, 611 patients were admitted with COVID-19, confirmed by either reverse-transcriptase polymerase chain reaction or computed tomography (CT). There were 363 males, and the age ranged from 18 to 98 years, with an average age of 57±15 years. Of these, 165 participants had severe disease (53 deaths, case fatality rate: 8.7%). Among those with hypertension (n=249), ARB exposure was compatible with decreased odds (OR=0.60, 95% CI: 0.27–1.36, p=0.31) of severe disease though not statistically significant, while ACEi exposure significantly reduced the risk of severe disease (OR=0.37, 95% CI: 0.15–0.87, p=0.03). ACEi exposure was associated with milder infiltrations seen on baseline CT, lower C-reactive protein and ferritin, higher monocytes, shorter hospitalization, and less requirement for specific empirical treatments (favipiravir and meropenem).Conclusion:Our data suggest that exposure to ACEi drugs may have favorable effects in the context of COVID-19 pneumonia.

Diabetic patients need higher furosemide doses: a report on acute and chronic heart failure patients.

Diuretics are first-line drugs in symptomatic heart failure treatment. Diabetes mellitus has been suggested as a determinant of diuretic resistance. Studies comparing the dose and efficacy of diuretics in patients with and without diabetes are lacking. We aimed to study if furosemide dose differed according to diabetes status. We studied two cohorts of heart failure patients: a cohort of acute heart failure patients consecutively hospitalized with the primary diagnosis of heart failure and another of stable and optimized patients followed in a heart failure clinic. Data on comorbidities and medication were abstracted from patients' files. Use and doses of furosemide were compared between diabetic and nondiabetic patients. Regression analysis was used to determine the association of variables with diuretic dose. The independent association of diabetes with furosemide dose was assessed using multivariate models. We studied 865 heart failure patients: 601 acute heart failure patients and 264 chronic stable heart failure patients. Acute heart failure patients with diabetes were more likely to need intravenous diuretic therapy and they were also more often discharged under higher doses of furosemide. They needed extra 6-mg furosemide at discharge in comparison with their nondiabetics counterparts and had an independent 26% higher odds of being discharged with at least 80-mg furosemide. Chronic patients were also more frequently prescribed with furosemide and on higher doses, although, diabetes was not independently associated with the use of higher furosemide doses. Diabetic patients are more intensively treated with the loop diuretic furosemide. In acute heart failure, diabetes is an independent predictor of furosemide dose.

Pamidronate as first-line treatment of hypercalcemia in neonatal subcutaneous fat necrosis: A case series.

Subcutaneous fat necrosis (SCFN) can be complicated by severe hypercalcemia, which is frequently asymptomatic. Nephrocalcinosis is associated with hypercalcemia and, in other clinical settings, has been linked to furosemide and glucocorticoid use. First-line bisphosphonate therapy treating hypercalcemia in neonatal SCFN is not well described. To describe the biochemical changes and risk of nephrocalcinosis in infants with hypercalcemia, secondary to neonatal SCFN, treated with initial pamidronate. A retrospective chart review of five infants treated with initial pamidronate and without furosemide or glucocorticoids. Data were collected on the following: timing of presentation, therapeutic response, and presence of nephrocalcinosis. Hypercalcemia resolved after 2.8±1.7 days; this is compared to 7.6±2.8 days from previously reported cases utilising alternative therapies (P=0.012). There were no episodes of rebound hypercalcemia or hypocalcemia. Nephrocalcinosis was present in four of five cases. When including published cases, age at diagnosis was associated with presenting serum calcium (P=0.003) and nephrocalcinosis was associated with higher serum calcium (P=0.014) and time from SCFN to hypercalcemia diagnosis (P=0.002). This retrospective case series demonstrates that first-line pamidronate treatment was effective and safe in the resolution of hypercalcemia. Nephrocalcinosis was observed, despite the avoidance of furosemide and glucocorticoid therapy, and associated with greater disease severity and duration of hypercalcemia.

Use of Intravenous Furosemide to Prevent Febrile UTI Following Flexible Ureterorenoscopic Laser Lithotripsy


 
 
 
 Introduction: Flexible ureterorenoscopic laser lithotripsy is the preferred management option for renal stones less than 2 cm. However, flexible ureterorenoscopic laser lithotripsy is not without complications and urinary tract infection is the most common reported complication. Prophylactic antibiotic use, access sheath, low pressure irrigation are few methods to reduce incidence of urinary tract infection. We have studied whether routine use of intravenous furosemide reduces the incidence of febrile urinary tract infection.
 Methods: A total of 70 patients were randomized into two groups where one received intravenous furosemide at the beginning of the procedure and another did not. Flexible ureteroscopic holmium laser lithotripsy was done and patients were followed up for development of febrile urinary tract infection within one week of the procedure.
 Results: 14% of patients who received furosemide and 20% of patients who did not receive developed post- operative febrile urinary tract infection within one week. Two patients in each group had bacteriuria.
 Conclusions: Although the incidence of febrile UTI is lesser with routine use of intravenous furosemide during flexible ureterorensocopic laser lithotripsy, statistical significance could not be proved.
 
 
 

Clinical Interventions to Prevent Tumour Lysis Syndrome in Hematologic Malignancy: A Multisite Retrospective Chart Review

Tumour lysis syndrome (TLS) occurs when lysis of malignant cells causes electrolyte disturbances and potentially organ dysfunction. Guidelines recommending preventive therapy according to TLS risk are based on low-quality evidence. The primary objective was to characterize utilization of TLS preventive strategies through comprehensive description of current practice. Secondary objectives were to determine TLS incidence, to compare use of preventive strategies among intermediate- and high-risk patients, and to describe TLS treatment strategies. This retrospective chart review examined data for patients with newly diagnosed hematologic malignancy who were admitted to an oncology centre and/or affiliated intensive care unit between October 2015 and September 2016 in Toronto, Ontario, Canada. Fifty-eight patients (29 at intermediate risk, 29 at high risk) were eligible for inclusion. Use of preventive allopurinol, IV bicarbonate, and furosemide was similar between groups. Rasburicase was more frequently used for high-risk patients (3% [1/29] of intermediate-risk patients versus 36% [9/25] of high-risk patients; p = 0.003). In 4 (14%) of the intermediate-risk patients and 2 (8%) of the high-risk patients, TLS developed during the admission. TLS was observed in 10% (1/10) of patients who received preventive rasburicase and 11% (5/44) of those who did not (p > 0.99), and in 9% (4/45) of patients who received preventive IV bicarbonate and 25% (2/8) of those who did not (p = 0.22). Treatment strategies included rasburicase, IV bicarbonate, furosemide, and renal replacement therapy. In this retrospective chart review, rasburicase was more commonly used for high-risk patients, whereas the use of other agents was similar between risk groups. This pattern of use is inconsistent with guidelines, which recommend that all high-risk patients receive rasburicase. There was no difference in TLS incidence between patients who did and did not receive preventive rasburicase or IV bicarbonate. Further prospective studies are needed to inform management of patients with malignancies who are at intermediate or high risk of TLS.

Case Report: Acute pancreatitis as a complication for the use of furosemide during transurethral resection of the prostate

Background: Pancreatitis caused after transurethral resection of the prostate (TURP) is an uncommon complication, with few reports found in the literature. Here we present the case of a middle-aged patient without comorbidities with this pathology. Clinical case: A 66-year-old male patient with no prior medical history underwent TURP surgery due to benign prostatic hyperplasia. The evolution was unfavourable, leading to post TURP syndrome. On the fifth day after surgery, the patient was admitted for emergency dialysis. During his emergency stay, the patient was unstable; he was diagnosed with pancreatitis, moving to an intensive care unit for management The patient progressed favourably from renal failure and pancreatitis, and on the 5th day the patient was discharged, tolerating oral feeding and stabilized renal failure. Conclusions: Pancreatitis caused by TURP is very rare. This complication has been reported in the literature infrequently and should be suspected when there is pain in the epigastrium. If this complication is suspected, imaging tests and pancreatic enzyme levels should be immediately requested, as it can have an unfavourable evolution until death.

Factors Associated with Deep Vein Thrombosis in Type 2 Diabetics with Biopsy-Proven Non-alcoholic Fatty Liver Disease

Non-alcoholic fatty liver disease (NAFLD) can lead to a prothrombotic stage increasing the risk of deep vein thrombosis (DVT). We aimed to assess the prevalence and factors associated with DVT in patients with type 2 diabetes (T2D) and biopsy-proven NAFLD. Using ICD-codes, all T2D patients who had liver biopsy done for suspected NAFLD were identified and assessed. Patients with secondary causes of hepatic steatosis (Hepatitis, excess alcohol, etc.) were excluded. Liver biopsy was staged as F0-4, advanced fibrosis (AF) being F3-4. A univariable and multivariate analysis was performed to assess factors associated with DVT. A total of 1295 patients were included in the final analysis. DVT was present in 5.5% of these patients. Our cohort consisted of 62% females, 90% were Caucasians, and 90% were obese or overweight (p = 0.59, 0.22, and 0.53, respectively). Mean platelet count was 200.1 ± 82.2 (p = 0.048) and mean HbA1c was 6.9 ± 1.7 (p = 0.71). On multivariate analysis, a 5-year increment in the age at time of T2D diagnosis was associated with 10% increase in likelihood of having DVT (OR {95% CI} 1.1 (1.01, 1.3), p = 0.031). Patients with IBD were 3-times more likely to have DVT than those without IBD and being on furosemide was associated with 2.5-times higher odds of DVT (OR {95% CI} 3.0 (1.3, 7.1), p = 0.012 and 2.5 (1.5, 4.1), p < 0.001, respectively). Our study suggests that older age, stricturing IBD disease, and use of furosemide in T2D with NAFLD increase the risk of DVT. Future prospective studies are required to confirm these findings. Clinical trial registration number: CCF 16-018

The Effects of Furosemide on Oxygenation in Mechanically Ventilated Children with Bronchiolitis.

Fluid balance management, including diuretic administration, may influence outcomes among mechanically ventilated children. We retrospectively compared oxygenation saturation index (OSI) before and after the initial furosemide bolus among 65 mechanically ventilated children. Furosemide was not associated with a significant change in median OSI (6.25 [interquartile range: 5.01-7.92] vs. 6.06 [4.73-7.54], p = 0.48), but was associated with expected changes in fluid balance and urine output. Secondary analysis suggested more favorable effects of furosemide in children with worse baseline OSI. The reported common use of furosemide by pediatric intensivists obligates further study to better establish its efficacy, or lack thereof, in mechanically ventilated children.

Prospective evaluation of immune haemolysis in liver transplantation.

Immune haemolysis in liver transplant (LT) can occur due to autoantibodies and alloantibodies. The aim of this study was to evaluate the prevalence and risk factors for immune haemolysis in LT. A total of 175 consecutive patients were included. Multiorgan recipients were excluded. Samples, from before LT, seven consecutive days and weekly for 4weeks, were evaluated for haemolysis and immunohaematological tests. SPSS 24 was used for statistical analysis. Nine patients (5·1%) presented positive antibody screen (AS) before LT, (2·3% clinically significant), more frequent in RhD-negative (P=0·017). Positive DAT occurred in 53 (30·3%) and was related to high MELD score (P=0·048), HCV (P=0·005) and furosemide use (P=0·001). Positive AS after LT occurred in 22 patients (12·5%), with nine (5·7%) clinically significant antibodies. Positive AS occurred more frequently in RhD negative (P=0·021) and in those transfused (P=0·022). Post-transplant positive DAT was associated with piperacillin-tazobactam use (P=0·021) and minor ABO incompatibility (P=0·0038). Five patients presented passenger lymphocyte syndrome (PLS), all received liver-graft O, four presented haemolysis, and three were transfused due to PLS. Auto- and alloantibodies against red blood cell antigens are frequent in LT, but the frequency of immune haemolysis was only 2·8%. The only risk factor for PLS was minor ABO mismatch.

Furosemide use and survival in patients with esophageal or gastric cancer: a population-based cohort study

BackgroundPre-clinical studies have shown that furosemide slows cancer cell growth by acting on the Na-K-2Cl transporter, particularly for gastric cancer cells. However, epidemiological studies have not investigated furosemide use and mortality in gastroesophageal cancer patients. Consequently, we conducted a population-based study to investigate whether furosemide use is associated with reduced cancer-specific mortality in esophageal/gastric cancer patients.MethodsA cohort of patients newly diagnosed with esophageal or gastric cancer between 1998 and 2013 were identified from English cancer registries and linked to the Clinical Practice Research Datalink to provide prescription records and the Office of National Statistics to provide death data up to September 2015. Time-dependant Cox-regression models were used to calculate hazard ratios (HRs) comparing cancer-specific mortality in furosemide users with non-users. Analyses were repeated restricting to patients with common furosemide indications (heart failure, myocardial infarction, edema or hypertension) to reduce potential confounding.ResultsThe cohort contained 2708 esophageal cancer patients and 2377 gastric cancer patients, amongst whom 1844 and 1467 cancer-specific deaths occurred, respectively. Furosemide use was not associated with reduced cancer-specific mortality overall (adjusted HR in esophageal cancer = 1.28, 95% CI 1.10, 1.50 and in gastric cancer = 1.27, 95% CI 1.08, 1.50) or when restricted to patients with furosemide indications before cancer diagnosis (adjusted HR in esophageal cancer = 1.07, 95% CI 0.88, 1.30 and in gastric cancer = 1.18, 95% CI 0.96, 1.46).ConclusionsIn this large population-based cohort study, furosemide was not associated with reduced cancer-specific mortality in patients with esophageal or gastric cancer.

Prevalence and Risk Factors for Hyponatremia in Preterm Infants.

BACKGROUND:Hyponatremia is the result of a negative sodium balance caused by inadequate salt intake or excessive salt loss due to immature renal or intestinal function in preterm infants.AIM:The aim of our study was to define the incidence of and factors affecting its development in preterm newborns.METHODS:This was a retrospective cohort analysis of 126 preterm infants born before 36 weeks of gestation between June 2016 and July 2018 at Neonatal Intensive Care Unit of Hue Central Hospital, Vietnam. Hyponatremia was defined as a sodium level ≤ 132 mEq/L or 133-135 mEq/L with oral sodium supplementation. We used the serum sodium level to define hyponatremia.RESULTS:There were 37 infants who had hyponatremia, accounting for 29.4% of the infants enrolled in the study. Alower gestational age, the presence of respiratory distress syndrome, the use of furosemide, and feeding with breast milk were significant risk factors for hyponatremia in preterm newborns.CONCLUSION:Hyponatremia occurred at a relatively high frequency. This result exemplifies the importance of serum sodium monitoring and supplementation for the correction of hyponatremia.

Meta-Analysis Comparing Torsemide Versus Furosemide in Patients With Heart Failure

Although torsemide's oral bioavailability and half-life theoretically render it a more efficient diuretic than furosemide, the clinical outcomes of torsemide compared with furosemide remain unclear. We performed a systematic review and meta-analysis, including all published studies that compared torsemide and furosemide use in heart failure patients from January 1996 through August 2019. Nineteen studies (9 randomized control trials [RCTs] and 10 observational studies) with a total of 19,280 patients were included. During a mean follow-up duration of 15 months, torsemide was associated with a numerically lower risk of hospitalization due to heart failure (10.6% vs 18.4%; odds ratio [OR] 0.72, 95% confidence interval [CI] [0.51, 1.03], p = 0.07, I2 = 18%; number needed to treat [NNT] = 23) compared with furosemide. Torsemide was associated with statistically significant more improvement in functional status from New York Heart Association (NYHA) class III/IV to I/II (72.5% vs 58%; OR 2.32, 95% CI (1.32, 4.1), p = 0.004, I2 = 27%; NNT = 5) and lower risk of cardiac mortality (1.5% vs 4.4%; OR 0.37, 95% CI (0.20, 0.66), p <0.001, I2 = 0%, NNT = 40) compared with furosemide. However, there was no difference in all-cause mortality or medication side effects between the 2 groups. In conclusion, compared with furosemide, torsemide use was associated with significant more improvement in functional status and lower cardiac mortality; and numerically fewer hospitalizations in patients with heart failure.

Influence of Long-Term Furosemide Use on Bone Mineral Content, Bone Metabolism Markers, and Water Weight Loss in Horses

Furosemide is used to reduce the incidence of exercise-induced pulmonary hemorrhage in racehorses. Previous research suggests furosemide negatively impacts calcium balance, which may have long-term implications for bone health. Eleven healthy horses, either control (CON, n = 5) or treatment (FUR, n = 6), were used to test furosemide’s effects on bone mineral content (BMC), bone metabolism biomarkers, and weight loss after administration. Treatment horses received IV furosemide at 1 mg⋅kg−1 BW once weekly for seven weeks, and blood was collected before and at 24 hours after administration for biomarker analysis. All horses were weighed before and at 2, 4, 8, 24, and 48 hours after administration. Radiographs of the left third metacarpal were taken every 28 days for BMC determination using radiographic bone aluminum equivalence. After administration, FUR lost more BW than CON (P < .05 for all) as quickly as 2 hours after administration (CON: −0.4 ± 0.3%, FUR: −2.2 ± 0.3%), and these losses remained greater than CON at 4 hours (CON: −1.0 ± 0.3%, FUR: −3.3 ± 0.3%) and 8 hours (CON: 0.0 ± 0.3%, FUR: −1.2 ± 0.3%). FUR lost more BW on day 0 than CON (P = .03), but on day 28 and day 49, FUR BW losses were no greater than CON (P > .10). No treatment effects were observed for BMC nor pyridinoline and osteocalcin concentrations (P > .10). Reduced BW changes over time in FUR but not CON warrant further investigation to establish the efficacy of frequent furosemide administration over long periods of time.

Acute Kidney Injury After Pediatric Liver Transplantation

BackgroundThe aim of the present study is to assess acute kidney injury (AKI) incidence according to the pRIFLE and AKIN criteria and to evaluate the risk factors for early developing AKI in postoperative intensive care unit after pediatric liver transplantation (LT). MaterialsAfter exclusion of retransplantations, 7 cadaveric and 44 living donors, totaling 51 pediatric LT patients that were performed between 2005 and 2017, were reviewed retrospectively. AKI was defined according to both pediatric RIFLE (Risk for renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function, and End-stage renal disease) and Acute Kidney Injury Network (AKIN) criteria. Documented data were compared between AKI and non-AKI patients. ResultsAKI incidences were 17.6% by AKIN and 37.8% by pRIFLE criteria. AKIN-defined AKI group had statistically lower serum albumin level, higher serum sodium level, higher furosemide dose, and higher rate of red blood cell (RBC) transfusion than the non-AKI group (P = .02, P = .02, P = .01 and P = .04, respectively). AKI patients had significantly prolonged mechanical ventilation (P = .01) and hospital LOS (P = .02). The pRIFLE-defined AKI group had significantly lower serum albumin level, higher blood urea nitrogen (BUN) level, and higher ascites drained and also showed higher requirement for RBC and 20% human albumin transfusions than the non-AKI group (P = .02, P = .04, P: =.007, P = .02 and P = .05, respectively). ConclusionWe evaluated that hypoalbuminemia, high requirement for RBC and 20% human albumin transfusions, high serum sodium, high furosemide use, and high flow of ascites are risk factors for AKI and high BUN levels can be predictive for AKI in pediatric LT patients. The effect of AKI on outcome variables were prolonged mechanical ventilation and hospital LOS.

Short-term diuretic withdrawal in stable outpatients with mild heart failure and no fluid retention receiving optimal therapy: a double-blind, multicentre, randomized trial.

Although loop diuretics are widely used to treat heart failure (HF), there is scarce contemporary data to guide diuretic adjustments in the outpatient setting. In a prospective, randomized and double-blind protocol, we tested the safety and tolerability of withdrawing low-dose furosemide in stable HF outpatients at 11 HF clinics in Brazil. The trial had two blindly adjudicated co-primary outcomes: (i) symptoms assessment quantified as the area under the curve (AUC) of a dyspnoea score on a visual-analogue scale evaluated at 4 time-points (baseline, Day 15, Day 45, and Day 90) and (ii) the proportion of patients maintained without diuretic reuse during follow-up. We enrolled 188 patients (25% females; 59 ± 13 years old; left ventricular ejection fraction = 32 ± 8%) that were randomized to furosemide withdrawal (n = 95) or maintenance (n = 93). For the first co-primary endpoint, no significant difference in patients' assessment of dyspnoea was observed in the comparison of furosemide withdrawal with continuous administration [median AUC 1875 (interquartile range, IQR 383-3360) and 1541 (IQR 474-3124), respectively; P = 0.94]. For the second co-primary endpoint, 70 patients (75.3%) in the withdrawal group and 77 patients (83.7%) in the maintenance group were free of furosemide reuse during follow-up (odds ratio for additional furosemide use with withdrawal 1.69, 95% confidence interval 0.82-3.49; P = 0.16). Heart failure-related events (hospitalizations, emergency room visits, and deaths) were infrequent and similar between groups (P = 1.0). Diuretic withdrawal did not result in neither increased self-perception of dyspnoea nor increased need of furosemide reuse. Diuretic discontinuation may deserve consideration in stable outpatients with no signs of fluid retention receiving optimal medical therapy. NCT02689180.

Effect of furosemide on muscle cramps in patients with liver cirrhosis.

Patients with cirrhosis usually experience muscle cramps of varying severity. Although diuretics have been reported to cause muscle cramps, clinical evidence is limited. Also, it has been pointed out that the use of diuretics is associated with the progression of sarcopenia in patients with cirrhosis. We conducted a questionnaire survey to clarify the effects of diuretics and skeletal muscle loss on muscle cramps. Overall, we enrolled 152 adults with cirrhosis in this study. Cramp questionnaires were obtained after informed consent. Study variables (demographics, physical findings, serum metabolic panel, and drugs taken that affect muscle cramps) were extracted from medical records. Body composition, including muscle volume, was analyzed using a bioelectrical impedance analysis method, and muscle strength (handgrip) was evaluated at enrollment. Cross-sectional skeletal muscle area was evaluated on computed tomography imaging at the L3 vertebral level to investigate the relationship between muscle cramps and sarcopenia. The proportion of furosemide administration was higher in patients with cramping compared with those without. On a multivariate logistic regression analysis, furosemide use was a significant factor in the presence of muscle cramps. Furthermore, regarding factors contributing to muscle cramp severity, furosemide use was extracted by multivariate logistic regression analysis. In the presence or severity of muscle cramps, skeletal muscles did not show any significant difference. Furosemide use for patients with cirrhosis was considered a risk factor for occurrence and severity of muscle cramps. On the other hand, skeletal muscle mass loss was not associated with muscle cramps.

Evolution of diagnostic criteria for acute kidney injury in patients with decompensated cirrhosis: A prospective study in a tertiary university hospital

Recently, changes in acute kidney injury (AKI) diagnostic criteria have been proposed (ICA-AKI criteria). However, in Brazil there is a paucity of data and analyses that evaluate AKI in patients with cirrhosis and determine the impact of the implemented AKI criteria changes. Therefore, this study sought to evaluate the incidence of AKI in patients with cirrhosis; to evaluate the agreement between traditional and ICA-AKI criteria; and to assess its clinical and laboratory characteristics, etiologies, risk factors and outcomes. This is a prospective cohort study in hospitalized patients with cirrhosis and acute decompensation. The total number of hospitalizations was evaluated using the PWP statistical model for recurring events; P values<0.05 were considered significant. A total of 154 admissions of 75 patients were included in the study. Among the hospitalizations, 89 (57.79%) met the ICA-AKI criteria. There was substantial agreement between both AKI classifications (Kappa 0.7293). The main etiology of AKI was pre-renal (59.55%), followed by renal (26.96%) and hepatorenal syndrome (10.11%). A multivariate analysis uncovered risk factors for ICA-AKI, including the MELD score (P=0.0162, RR:1.055, 95%CI:1.010-1.101) and the use of furosemide (P=0.001,RR:2.360, 95% CI:1.417-3.931). A univariate analysis found an association between in-hospital mortality and serum creatinine (sCr)≥1.5mg/dL(P=0.0373), MELD (P=0.0296), bilirubin (P=0.0064), and infection (P=0.0045), while in the multivariate analysis, the bilirubin levels (P=0.0030, RR:1.077, 95%CI: 1.025-1.130) and the presence of shock (P=0.0002, RR:8.511, 95%CI: 2.746-26.377) were associated with in-hospital mortality. Among the hospitalizations with AKI, death was significantly associated with non-response to treatment and dialysis. Initial stage 1A-AKI had lower in-hospital mortality than stage 1B-AKI. AKI incidence was high in this cohort of patients with decompensated cirrhosis, and substantial agreement between AKI definitions was observed. In-hospital mortality was associated with worse liver function, AKI, infection and the presence of shock. Also, sCr>1,5mg/dL remained an important prognostic factor.

The use of Torsemide versus Furosemide in Patients with Heart Failure, a Systematic Review and Meta Analysis

Background Loop diuretics are recommended by current guidelines for patients with symptomatic heart failure (HF) with NYHA class II-IV. While torsemide's oral bioavailability and half life theoretically render it a more efficacious drug than furosemide, the clinical outcomes of torsemide compared with furosemide in patients with HF remain unclear. Methods We performed a meta-analysis including all published randomized control trial (RCTs) and observational studies that compared torsemide and furosemide use in chronic HF patients from inception to February 2019. Results Fifteen studies (eight RCTs and seven observational studies) including 9758 patients were included. Over a weighted mean follow-up duration of 8±3 months, torsemide was associated with a lower risk of rehospitalization due to HF (8.6% vs. 12.7%, NNT=23) (OR 0.63, 95% CI (0.44, 0.91), p=0.01, I2=8%) and cardiac mortality (1.6% vs. 4.4%, NNT=37) (OR 0.37, 95% CI (0.20, 0.66), p Conclusion Torsemide use improved functional status and reduced rehospitalization due to HF compared with furosemide in chronic HF patients. Torsemide was also associated with reduced cardiac mortality, but this effect requires further study.