title: Outcomes of diuretic use in pre-dialysis CKD patients with moderate renal deterioration attending tertiary care referral center.
abstract: BACKGROUND
  Diuretic therapy has been the mainstay of treatment in chronic kidney disease (CKD) patients, primarily for hypertension and fluid overload. Apart from their beneficial effects, diuretic use is associated with adverse renal outcomes. The current study is aimed to determine the outcomes of diuretic therapy.
  
  
  METHODS
  A prospective observational study was conducted by inviting pre-dialysis CKD patients. Fluid overload was assessed by Bioimpedance analysis (BIA).
  
  
  RESULTS
  A total 312 patients (mean age 64.5 ± 6.43) were enrolled. Among 144 (46.1%) diuretic users, furosemide and hydrochlorothiazide (HCTZ) were prescribed in 69 (48%) and 39 (27%) patients, respectively, while 36 (25%) were prescribed with combination therapy (furosemide plus HCTZ). Changes in BP, fluid compartments, eGFR decline and progression to RRT were assessed over a follow-up period of 1 year. Maximum BP control was observed with combination therapy (-19.3 mmHg, p < 0.001) followed by furosemide [-10.6 mmHg with 80 mg thrice daily (p < 0.001)], -9.3 mmHg with 40-60 mg (p < 0.001) and -5.9 mmHg with 20-40 mg (p = 0.02) while HCTZ offered minimal SBP control [-3.7 mmHg with 12.5-25 mg (p = 0.04)]. Decline in extracellular water (ECW) ranged from -1.5 L(p = 0.01) with thiazide diuretics to -3.8 L(p < 0.001) with combination diuretics. Decline in eGFR was maximum (-3.4 ml/min/1.73 m2, p = 0.01) with combination diuretics and least with thiazide diuretics (-1.6 ml/min/1.73 m2, p = 0.04). Progression to RRT was observed in 36 patients.
  
  
  CONCLUSIONS
  It is cautiously suggested to discourage the use of diuretic combination therapy and high doses of single diuretic therapy. Prescribing of diuretics should be done by keeping in view benefit versus harm for each patient.
authors.affiliation: Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, University Sains Malaysia, 11800,, Gelugor, Penang, Malaysia. yusrahabib@ymail.com.|Chronic Kidney Disease Resource Centre, School of Medical Sciences, Health Campus, University Sains Malaysia, 16150, Kubang Kerain, Kelantan, Malaysia. yusrahabib@ymail.com.
authors.forename: Yusra Habib
authors.initials: YH
authors.lastname: Khan
authors.affiliation: Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, University Sains Malaysia, 11800,, Gelugor, Penang, Malaysia.
authors.forename: Azmi
authors.initials: A
authors.lastname: Sarriff
authors.affiliation: Chronic Kidney Disease Resource Centre, School of Medical Sciences, Health Campus, University Sains Malaysia, 16150, Kubang Kerain, Kelantan, Malaysia.
authors.forename: Azreen Syazril
authors.initials: AS
authors.lastname: Adnan
authors.affiliation: Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, University Sains Malaysia, 11800,, Gelugor, Penang, Malaysia.
authors.forename: Amer Hayat
authors.initials: AH
authors.lastname: Khan
authors.affiliation: Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, University Sains Malaysia, 11800,, Gelugor, Penang, Malaysia.|Chronic Kidney Disease Resource Centre, School of Medical Sciences, Health Campus, University Sains Malaysia, 16150, Kubang Kerain, Kelantan, Malaysia.
authors.forename: Tauqeer Hussain
authors.initials: TH
authors.lastname: Mallhi
mesh_terms: D000368:Aged; D001794:Blood Pressure / Q000187:drug effects*; D004232:Diuretics / Q000494:pharmacology / Q000627:therapeutic use*; D005260:Female; D005665:Furosemide / Q000494:pharmacology / Q000627:therapeutic use; D005919:Glomerular Filtration Rate; D006801:Humans; D006852:Hydrochlorothiazide / Q000494:pharmacology / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D051436:Renal Insufficiency, Chronic / Q000188:drug therapy*; D062606:Tertiary Care Centers / Q000706:statistics & numerical data
chemical_list: D004232:Diuretics; D006852:Hydrochlorothiazide; D005665:Furosemide
keywords: Bioimpedance analysis; Blood pressure; Chronic kidney disease; Diuretics; Fluid overload