[Renaliste] diurese d 'entrainement/IRA et diuretiques de l'anse:utilit é ?

[Jean-Marie Faivre]

"Je ne pense pas" ............je constate (cf plus bas)
cela n'enleve rien a l'interet futur des anti-ADH, Lise ,qui seront plus
des " diuretiques de l'eau"
contrairement aux" salidiuretiques "  mais la question clinique  etait :
 le furosémide est prescrit dans de nombreux
> services d'urgence ou de réanimation pour prévenir ou traiter des
> insuffisances rénales aiguës , ou insuffisance rénale chronique modérée
> associée, associée à d'autres pathologies.
> la fameuse diurese forcée ou d 'entrainement apporte t elle un bénéfice
> quelconque...?

Avec les donnees de l'EBM  la reponse est deja acquise quelles que soient
les habitudes
JM Faivre

voici:
http://www.bestbets.org/cgi-bin/bets.pl?record=00304

Q The use of loop diuretics in acute renal failure in critically ill
patients to reduce mortality, maintain renal function or avoid the
requirements for renal support.
Report by:    Anthony Davis - SpR Anaesthesia
Search checked by:    Ingrid Gooch - SpR Anaesthesia
Institution:    Northwest School Anaesthesia, Manchester
Date submitted:    15th March 2005
Date completed:    23rd June 2006
Last modified:    10th February 2006
Status:     Green (complete)

Three part question
In [critically ill patients with acute renal failure] does [the use of loop
diuretics] [reduce mortality, improve renal function, reduce length of
ITU/hospital stay or reduce requirements for renal replacement therapy]?

Clinical scenario
A 65 year old male presents to the emergency department with a severe
pneumonia. He is intubated and placed on a ventilator because of worsening
hypoxia. He has no history of previous renal disease however he becomes
increasingly oliguric over the next 2 hours despite adequate fluid
resuscitation and vasopressor support.
You wonder whether the administration of a loop diuretic in order to
improve/maintain his urine output will improve his prognosis and reduce the
need for continuous veno-venous haemofiltration (CVVH).

Search strategy (methodologie)
Cochrane Database - Edition 2 2006
OVID Medline 1966 to February Week 1 2006.
Embase 1980-Feb 2006.
(exp Uraemia OR azotemia.mp OR exp Kidney Failure/ OR exp kidney failure,
acute/ OR exp kidney tubular failure, acute/ OR acute tubular necrosis.mp OR
acute renal failure.mp OR renal failure.mp OR acute kidney failure.mp OR
ARF.mp) AND (exp Diuretics/ OR Diuretics.mp, OR loop diuretic$.mp OR exp
furosemide/ OR frusemide.mp OR exp bumetanide/ OR bumetanide.mp OR
burinex.mp OR lasix.mp OR torasemide.mp OR Torem.mp) and ((critically ill or
critical illness).mp OR exp Critical Illness/ OR critical care.mp OR exp
Critical Care/ OR intensive care.mp OR intensive care units.mp OR exp
intensive care/) limited to English and humans.
Cochrane: loop diuretics

Search outcome
97 papers were found on Medline and 721 papers on Embase of which only 2
directly answered the three part question.
There were 209 citations in Cochrane. No new papers were found.

Relevant paper(s)
Mehta et al,
2004,
USA    552 critically ill patients with acute renal failure in 4 ITUs in
California. 326 patients (59%) were treated with diuretics.    Prospective
cohort study October 1989-1995.    Relationship between diuretic use and
mortality and non-recovery of renal function    Increased risk of death and
non-recovery of renal function with diuretic use. Odds Ratio 1.77 (CIs
1.14-2.76) in group given diuretics.    Prospective observational cohort
study.
Patients given diuretics were likely to be older and more likely to have a
history of CCF (p<0.001) and had lower measured Cardiac Index (p<0.001).
Some inclusion criteria debatable.
Odds ratio of death when patients who died in week 1 were excluded    Odds
ratio of death 3.12 (CIs 1.73-5.62)
Overall in-hospital mortality    Odds Ratio 1.68 (CIs 1.06-2.64)

Uchino et al,
2004,
Australia (Multicentre study 23 countries)    1743 patients on intensive
care units on renal replacement therapy or with acute renal failure (using
pre-defined criteria). 70% of patients were treated with diuretics at study
inclusion. Frusemide was most commonly used diuretic (98%).    Prospective
multicentre (54 centres), multinational (23 countries) cohort study. Three
distinct multivariate analyses were performed using propensity scoring.
Unadjusted hospital mortality rates    Diuretic group (62.4%) v controls
(57.1%). Odds ratio mortality 1.25 (p<0.03).    Observational cohort.
Heterogeneity of care across 23 countries.
Analytical methods can only adjust for observed confounding variables not
unobserved ones.
Adjustments using three multivariant models    Overall Odds ratio mortality
similar for all three methods. 1.21-1.22 (CIs 0.92 - 1.6) p=0.10 to p=0.153.

Comment(s)
About one fifth of the cardiac output is directed to the kidneys. This
exceeds the oxygen supply to other vital organs, such as the brain, heart,
or liver. A very low fraction of oxygen delivered is extracted by the
kidney, suggesting ample oxygen reserve. Paradoxically, the kidney is the
organ which is most sensitive to hypoperfusion and hypoxia, with acute renal
failure being one of the most frequent complications of hypotension. This is
because of the physiological gradient of intrarenal oxygenation, which means
that under normal physiological conditions the renal medulla functions at
very low oxygen tensions. Many therapeutic interventions in the prevention
or management of patients with acute renal failure have been investigated in
clinical studies. Interventions to enhance renal blood flow and decrease
tubular reabsorption seem to be a logical approach for the prevention of
outer medullary hypoxic injury. Loop diuretics block the active
sodium-potassium-chloride co-transport in the apical membrane of the thick
ascending limb renal tubular cells. The loop diuretic frusemide has been
shown to reduce medullary demand by inhibiting solute reabsorption and to
attenuate the severity of acute renal injury in animal models. It is
postulated that it may protect the human kidney from ischaemic injury. There
are some small studies of low statistical power, but they are confounded by
co-interventions such as low dose dopamine or mannitol. The best evidence to
answer this current clinical question comes from the two observational
cohorts identified in this review. The two studies collected over 2000
patients. They both document overall detriment with the use of diuretics
with odds ratios of >1.0, as opposed to benefit, although the BEST
investigators did not demonstrate statistical significance in their
findings. The question of whether an RCT can be justified on the basis of
these observational findings is debatable.

Clinical bottom line
In critically ill patients with acute renal failure, there is no evidence to
suggest that the use of loop diuretics reduces mortality, reduces length of
ITU/hospital stay or increases the recovery of renal function.

Level of evidence
Level 2 ­ Studies considered were neither 1 or 3.

References

   Mehta RL. Pascual MT. Soroko S et al. Diuretics, mortality, and
nonrecovery of renal function in acute renal failure. JAMA.
2002;288(20):2547-53.
   Uchino S. Doig GS. Bellomo R et al. Beginning and Ending Supportive
Therapy for the Kidney (B.E.S.T. Kidney) Investigators. Diuretics and
mortality in acute renal failure. Critical Care Medicine 2004;32(8):1669-77.

cf aussi rapport initial
http://www.bestbets.org/cgi-bin/bets.pl?record=00304

   Lumlertgul, D. Keoplung, M. Sitprija, V. Moollaor, P. Suwangool, P.
Furosemide and dopamine in malarial acute renal failure. Nephron 1989;
52(1):40-4.
   Hager B. Betschart M. Krapf R. Effect of postoperative intravenous loop
diuretic on renal function after major surgery. Journal Suisse de Medecine
1996;126(16):666-73.
   Shilliday IR, Quinn KJ, Allison ME. Loop diuretics in the management of
acute renal failure: A prospective, double-blind, placebo-controlled,
randomized study. Nephrol Dial Transplant 1997;12:2592 -2596.
   Sirivella S. Gielchinsky I. Parsonnet V. Mannitol, furosemide, and
dopamine infusion in postoperative renal failure complicating cardiac
surgery. Annals of Thoracic Surgery. 2000; 69(2):501-6.




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on 9/10/2006 17:57, Dan Teboulle at dan.teboulle at ch-mt-marsan.fr wrote:

> Message de la liste nephrologique francophone RENALISTE
> ----------------------------------
> Depuis de longues années le furosémide est prescrit dans de nombreux
> services d'urgence ou de réanimation pour prévenir ou traiter des
> insuffisances rénales aiguës , ou insuffisance rénale chronique modérée
> associée, associée à d'autres pathologies...
> la fameuse diurese forcée ou d 'entrainement apporte t elle un bénéfice
> quelconque...?
> ne cache t elle pas , parfois , une évolution naturelle qui sera alors
> difficile à évaluer..?
> est elle toxique ? pour le rein?
> 
> les néphrologues ont à ce sujet des habitudes différentes, il me semble...
> qu'en pensez vous....
> 
> dan teboulle
> chg mont de marsan
> 
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> 

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