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Role of Diuretics in the preservation of residual renal function in patients on continuous ambulatory peritoneal dialysis,[object Object],Lakshmi Turlapati, M.D.,[object Object],Journal Club, March 18,2010,[object Object]
Introduction,[object Object],Most patients upon initiation of dialysis have some degree of Residual renal function, and may have normal or even high rates of urine output. ,[object Object],This level of Residual renal function may persist for few years, adding continuous solute clearance to the intermittent clearances provided by dialysis treatments. ,[object Object],Residual renal function also helps in maintenance of steady state fluid balance which is important in preventing persistent volume overload, hypertension and cardiac hypertrophy.,[object Object]
Introduction,[object Object],Hence KDOQI guidelines recommend to preserve residual renal function.,[object Object],Strategies to preserve RRF include use of ACE/ARB, Control of BP, Avoiding nephrotoxins, Avoidance of excessive ultra filtration and hypotension, use of biocompatible dialyzer membranes, use of bicarbonate based dialysate, use of ultrapure dialysate.,[object Object]
Introduction,[object Object],This study investigates whether Furosemide given long term to patients on Peritoneal dialysis would preserve urine volume and slow the decline of Residual Renal function without unwanted side effects.,[object Object]
Study Design,[object Object],Prospective,[object Object],Randomized,[object Object],Open label,[object Object]
Methods,[object Object],61 new patients greater than 16 years of age starting CAPD were enrolled between June 1996 and November 1997.,[object Object],Followed for one year.,[object Object],Patients who had previously received more than 2 weeks of hemodialysis and those with a failing renal transplant were excluded.,[object Object]
Randomization and Treatment,[object Object],Randomized to receive either furosemide 250 mg daily or no treatment.,[object Object],Patients in diuretic treated group were given additionally Metolazone 5 mg orally daily if their urine volume did not exceed 500 ml/24 hrs at any follow up visit.,[object Object],Study assessment done at 6 and 12 months.,[object Object]
Randomization and Treatment,[object Object],Dialytic prescription was adjusted independent of the study and was guided by clinical parameters and calculated clearances.,[object Object],Urea clearance (Kt/V) of 1.7 or greater was obtained.,[object Object],Blood pressure was controlled, first by reduction of target weight before introduction of antihypertensives.,[object Object]
Role of diuretics in the preservation of residual
Study Measurements,[object Object],Urine volume was recorded at randomization, and at 6 and 12 months by 24 r collection,[object Object],Urinary and Dialytic urea and Crcl was calculated.,[object Object],Urinary electrolytes and osmolality were measured on 24 hr urine collections to allow calculation of free water and electrolyte free water clearances.,[object Object],PET test was done.,[object Object],Statistical Analysis was intention to treat using unpaired t test.,[object Object]
Results,[object Object],Urine volume at randomization was comparable between 2 groups.( 1020+-104 vs 1040+-130 ml/24 hrs),[object Object],After 1 year of CAPD, UV declined in control group to 733+-124 ml/24 hrs whereas in the diuretic treated group it was 1070+-193 ml/24 hrs.,[object Object],However, urinary urea and Crcl declined at a constant rate in both groups.,[object Object]
Role of diuretics in the preservation of residual
Role of diuretics in the preservation of residual
Role of diuretics in the preservation of residual
Discussion,[object Object],The study shows that Daily Furosemide maintains the urine volume over a year of PD by a clinically significant mean difference of 340 cc/day at one yr.,[object Object],However, it doesn’t slow the decline of urinary urea and Cr clearance.,[object Object],Although proportion of patients with DM was higher in the diuretic-treated group, repeat analysis excluding pts with diabetes showed similar results.,[object Object]
Discussion,[object Object],Strengths: randomized, prospective study.,[object Object],Limitations: small sample size, unknown race/drugs/comorbidities, Unknown if Bp control adequate in study.,[object Object]
Discussion,[object Object],However, since preservation of urine volume is beneficial to maintain steady state fluid balance, reduce volume overload between intermittent dialysis treatments and thus prevent cardiac hypertrophy, it might be beneficial to use furosemide in dialysis pts.,[object Object],DOPPS is a large scale observational study in HD patients showing that diuretic use is associated with reduction in all cause and cardiac mortality in HD patients.,[object Object],Further large scale randomized studies are needed to investigate this survival benefit.,[object Object]

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Role of diuretics in the preservation of residual

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  • 11.
  • 15.
  • 16.
  • 17.