Diuretic strategies in patients with resistance to loop-diuretics in the intensive care unit: A retrospective study from the MIMIC-III database

Purpose: To investigate various diuretic strategies to alleviate loop-diuretics resistance in critically ill patients. Materials and method: ICU adults requiring more than 1 mg/kg/day of furosemide, from the MIMIC-III database. Four diuretic strategies were investigated: incremental dose of loop diuretics, continuous infusion, combinations with a second class of diuretics and administration of intravenous albumin. A generalized estimating equation was used to investigate the associations between these strategies and endpoints. The primary outcome was the 24-h urine output and secondary endpoints included fluid balance, weight change, electrolyte and acid base abnormalities, kidney replacement therapy initiation, and mortality. Results: A total of 7645 ICU stays from 6358 patients were included. After adjustment, the use of continuous loop diuretic infusion was associated with a higher 24-h urine output (beta: 732, 95% CI:669-795, p < 0.001), lower 24-h fluid balance (p < 0.001) and greater weight loss at 48-h (p < 0.001). Thiazide-and carbonic anhydrase inhibitor combinations were both associated with higher urine output (p < 0.001) and weight loss at 48-h (p < 0.01), while intravenous albumin was associated with fluid gain (p < 0.001). Risks of electrolyte and metabolic disturbances varied across diuretic strategies. Conclusions: Continuous loop-diuretic infusion and thiazide-or acetazolamide-loop diuretic combinations increased urine output significantly, leading to a negative fluid balance and weight loss. (c) 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).

Automated summary

Continuous loop-diuretic infusion and combinations of loop diuretics with thiazide or carbonic anhydrase inhibitors significantly increased urine output, resulting in negative fluid balance and weight loss. Conversely, intravenous albumin administration was associated with fluid gain.