Revisiting diuretic choice in chronic kidney disease

Area of Science:

• Nephrology
• Pharmacology
• Internal Medicine

Background:

• Current guidelines lack specific recommendations for thiazide and loop diuretic use in chronic kidney disease (CKD).
• Recent research provides new insights into the efficacy and safety of these diuretics in CKD patients.

Purpose of the Study:

• To review recent studies on the indications and safety of thiazide and loop diuretics in patients with CKD.
• To address the evolving understanding of diuretic use in kidney disease management.

Main Methods:

• Literature review of recent studies impacting diuretic use in CKD.
• Synthesis of evidence regarding efficacy, safety, and specific patient populations.

Main Results:

• Chlorthalidone demonstrates blood pressure reduction in advanced CKD, challenging previous assumptions about thiazide efficacy at lower GFRs.
• No definitive impact of thiazide or loop diuretics on kidney or cardiovascular outcomes in CKD was found.
• Sodium-glucose co-transporter type 2 (SGLT2) inhibitors possess diuretic effects, and their benefits against acute kidney injury (AKI) are not diminished by concomitant diuretic use.
• Thiazide diuretics may not worsen polycystic kidney disease progression and could help manage tolvaptan-induced polyuria.
• Adverse effects include electrolyte disturbances, decreased eGFR, and AKI.

Conclusions:

• Recent evidence supports broader use of diuretics, such as chlorthalidone for hypertension in advanced CKD.
• Close monitoring of electrolytes and eGFR is crucial for safe and effective diuretic therapy in CKD patients.