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In This Article
 »  Abstract
 » Introduction
 » Case Report
 » Discussion
 »  References

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DRUG WATCH
Year : 2011  |  Volume : 43  |  Issue : 5  |  Page : 603-604
 

Diuretics induced uremia and nonrecovery of renal function in a patient with acute renal failure caused by sepsis


1 Department of Pharmacology, School of Pharmaceutical Sciences, Siksha O Anusandhan University, Bhubaneswar, Orissa, India
2 Department of Pharmacology,Hi tech College of Pharmacy, Bhubaneswar, Orissa, India

Date of Submission14-Jan-2011
Date of Decision20-May-2011
Date of Acceptance01-Jul-2011
Date of Web Publication15-Sep-2011

Correspondence Address:
P K Sahu
Department of Pharmacology, School of Pharmaceutical Sciences, Siksha O Anusandhan University, Bhubaneswar, Orissa
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0253-7613.84983

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 » Abstract 

Sepsis is a clinical syndrome related to severe infection and is characterized by systemic inflammation and injury to multiple organs and functional systems. Sepsis is one of the main causes of acute renal failure (ARF). Diuretics are frequently administered during ARF. However, there is scant evidence that diuretics provide any benefit to the patients with ARF. This case report highlights the occurrence of uremia and nonrecovery of renal function after administration of diuretics in a patient with ARF caused by sepsis. It is suggested that physicians should be cautious in prescribing diuretics to patients with ARF due to septicemia. Diuretics cause uremia and may lead to false diagnosis of chronic renal failure and nonrecovery of renal function. The patient may unnecessarily require prolonged dialysis.


Keywords: Dialysis, diuretics, sepsis, uremia


How to cite this article:
Sahu P K, Pal A, Panda J, Patnaik S. Diuretics induced uremia and nonrecovery of renal function in a patient with acute renal failure caused by sepsis. Indian J Pharmacol 2011;43:603-4

How to cite this URL:
Sahu P K, Pal A, Panda J, Patnaik S. Diuretics induced uremia and nonrecovery of renal function in a patient with acute renal failure caused by sepsis. Indian J Pharmacol [serial online] 2011 [cited 2019 Sep 20];43:603-4. Available from: http://www.ijp-online.com/text.asp?2011/43/5/603/84983



 » Introduction Top


Sepsis is a clinical syndrome related to severe infection and is characterized by systemic inflammation and injury to many organs and functional systems. [1],[2] It is usually treated with antibiotics, surgical drainage of infected fluid collections, and fluid replacement. Appropriate support for organ dysfunction is provided by hemodialysis in kidney failure, mechanical ventilation in pulmonary dysfunction, transfusion of blood products, and drug and fluid therapy for circulatory failure. [3]

Sepsis is one of the main causes of acute renal failure (ARF). The mechanism by which sepsis may lead to ARF is not well understood. However, loss of sympathetic nervous system autoregulation, systemic hypotension, direct renal vasoconstriction, release of cytokines, etc. are some of the factors which might contribute to renal ischemia and renal injury. [4],[5] Diuretics are frequently administered to augment renal salt and water excretion in the setting of extracellular volume of overload in ARF patients. [6] The use of diuretics in ARF due to sepsis may not always be beneficial to the patient. We report a case of uremia, nonrecovery of renal function, and chronic renal failure (CRF) caused by diuretics in a patient of sepsis with ARF and undergoing dialysis.


 » Case Report Top


A 61-year-old man with continuous high-grade intermittent fever associated with chills and rigor (8 days), hiccup (8 days), nausea (1-2 days), and breathlessness (1 day) reported to the outpatient department (OPD) of Neelachal Hospital Pvt Ltd, Bhubaneswar. The patient was administered with arteether 150 mg i.v. OPD in another private clinic prior to admission. The patient was a known case of hypertension with cerebrovascular accident (CVA) and right-sided hemiparesis since 13 years and was on atenolol 75 mg, amlodipine 7.5 mg, amiloride 40 mg, and aspirin 50 mg once daily.

At the time of admission, the patient was confused with temperature 104΀F, pulse 110/min, blood pressure 130/80 mmHg, respiration rate 40/min, SPO 2 96%, pallor, and normal blood sugar and ultrasonography (USG) of whole abdomen. An increase in serum urea (76 mg/dl), serum creatinine (3.2 mg/dl), serum glutamic oxaloacetic transaminase (40 IU/L), serum glutamic pyruvic transaminase (49 IU/L), and total leukocytic count/TLC (10600) was observed. tests for Plasmodium vivax, Plasmodium falciparum, Hepatitis C Virus (HCV), and Australian antigen were found to be negative.

The patient was diagnosed as a case of sepsis with ARF and was administered with antibiotics such as ceftriaxone and tazobactam for 4 days. However, arteether 150 mg i.v. once daily was continued as the patient belonged to a malaria prone area. There was no relief in any of the symptoms and the serum urea and creatinine levels increased progressively daily. The urine output however remained normal. Hence, on the 5 th day the two antibiotics were replaced by teicoplanin and meropenem. Hemodialysis was started from the 6 th day. On the 7 th day, the symptoms start abated, but the serum urea (116 mg/dl) and creatinine (4.3 mg/dl) levels and the TLC (11900/cumm) were raised. On the 10 th day, there was an increase in serum urea (168 mg/dl) and creatinine (4.34 mg/dl) levels and TLC (21600/cumm). Hence, the two antibiotics and arteether were stopped and administration of three diuretics (Furosemide 40 mg twice daily, torsemide 20 mg twice daily, and metolazone 5 mg once daily) and one antibiotic (Cefotaxime 1 g twice daily) were started in addition to hemodialysis once in every 3-4 days. The nephrologists administered three diuretics together with the objective that increased urination would decrease serum urea and creatinine. On the 12 th day however, the TLC (31000), serum urea (219 mg/dl), and creatinine (4.64 mg/dl) increased further. The day after hemodialysis, urea and creatinine levels decreased but again increased requiring another dialysis within 3-4 days. Hence, tigecycline 50 mg twice daily on the 17 th day and caspofungin 50 mg once daily on the 24 th day were added. On the 29 th day, the TLC decreased and another antibiotic (doripenem 250 mg twice daily) was added. On the 35 th day, all the antibiotics were stopped as the TLC became almost normal (11000/cumm). However, the serum urea (400 mg/dl) and creatinine (3.6 mg/dl) remained high. The patient was diagnosed as a case of CRF and dialysis at regular intervals was recommended.

After consultation with a nephrologist from another organization, on the 41 st day, two diuretics (torsemide 20 mg twice daily and metolazone 5 mg once daily) were stopped. The next day (42 nd day) urea and creatinine levels decreased to 208 mg/dl and 2.2 mg/dl, respectively. On the 43 rd day, furosemide was stopped. The serum urea and creatinine levels started decreasing and by 60 th day, they were normal (TLC 7700/cumm, urea 27 mg/dl, and creatinine 1.1 mg/dl). Dialysis was not required further after stopping the administration of diuretics.


 » Discussion Top


ARF is one of the most serious complications of sepsis. Since its occurrence prominently affects the outcome, it is important to distinguish patients who eventually will develop ARF, making it possible to correct the factors predisposing to ARF. It is important to prevent ARF by careful monitoring and aggressive treatment of patients at risk. [7]

Diuretics are frequently given during ARF in an effort to convert oliguric to nonoliguric ARF, since oliguria has been recognized as a proxy for the severity of ARF and the likelihood of requiring dialysis. [8],[9] Despite the ubiquity of this practice, there is scant evidence that diuretics provide any material benefit to patients with ARF. Mehta et al. showed that the diuretic use in the Intensive Care Unit (ICU) patients with ARF was associated with greater in-hospital mortality and nonrecovery of renal function. [10]

Infectious causes have consistently ranked second to cardiovascular disease in reported causes of death in patients on dialysis. Several studies suggest that septicemia rates in these patients are higher than in general population. Uremia is a classic state of hyper responsiveness, and infection rates are believed to be several times higher in dialysis populations than in the age-matched segments of the general population. [11] The increase in mortality and nonrecovery of renal function in ARF patients may be due to a direct deleterious effect of diuretic agents, or a delay in the institution of renal support (in effect, forestalling dialysis with volume overload or with anticipated reversal of azotemia), or other unknown factors. [10] Therefore, uremia in this case may be caused by dialysis and/or use of diuretics.

An increase in TLC is a sign of infection [12] and when it decreased to normal in this case, the patient was free from infection. Hence, all the antibiotics were stopped, but urea and creatinine levels remained high. The renal function recovered after diuretics were stopped, and no dialysis was required.

In the view of these findings, it is suggested that physicians should be cautious in prescribing diuretics to patients with ARF due to sepsis. The use of diuretics in ARF may not be helpful, but harmful. It may lead to false diagnosis of CRF and nonrecovery of renal function. The patient may unnecessarily require prolonged dialysis.

 
 » References Top

1.Bone RG. The pathogenesis of sepsis. Ann Intern Med 1991;115:457-69.  Back to cited text no. 1
    
2.Bone RG. Immunologic dissonance: A continuing evolution in our understanding of the systemic inflammatory response syndrome (SIRS) and the multiple organ dysfunction syndromes (MODS). Ann Intern Med 1996;125:680-7.  Back to cited text no. 2
    
3.Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, et al. Surviving Sepsis campaign: International guidelines for management of severe sepsis and septic shock. Crit Care Med 2008;36:296-327.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Schor N. Acute renal failure and sepsis syndrome. Kidney Int 2002;61:764-76.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Thijs A, Thijs LG. Pathogenesis of renal failure in sepsis. Kidney Int Suppl 1998;66: S34-7.  Back to cited text no. 5
[PUBMED]    
6.Venkataram R, Kellium JA. The role of diuretic agents in the management of acute renal failure. Contrib Nephrol 2001;132:158-70.  Back to cited text no. 6
    
7.Hoste EA, Lameire NH, Vanholder RC, Benoit DD, Decruyenaere JM, Colardyn FA. Acute renal failure in patients with sepsis in surgical ICU: Predictive factors, incidence, comorbidity and outcome. J Am Soc Nephrol 2003;14:1022-30.  Back to cited text no. 7
[PUBMED]  [FULLTEXT]  
8.Klahr S, Miller SB. Acute oliguria. N Engl J Med 1998;338:671-5.  Back to cited text no. 8
[PUBMED]  [FULLTEXT]  
9.Wilson WC, Aronson S. Oliguria: A sign of renal success or impending renal failure? Anesthesiol Clin North America 2001;19:841-83.  Back to cited text no. 9
[PUBMED]    
10.Mehta RL, Pascual MT, Soroko S, Chertow GM. Diuretics, mortality, and nonrecovery of renal function in acute renal failure. JAMA 2002;288:2547-53.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Foley RN. Infectious complications in chronic dialysis patients. Perit Dial Int 2008;28: S167-71.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Chakraborty P. Practical Pathology. Kolkata: New Central Book Agency (P) Ltd.; 2010. p.41-4.  Back to cited text no. 12
    




 

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