Use of Diuretics in Chronic Kidney Disease Patients
Diuretics are commonly prescribed to treat the sodium retention, volume expansion, and hypertension characteristic of chronic kidney disease (CKD). With reduced renal function, delivery of the drugs to their renal tubular sites of action is impaired, potentially leading to diminished potency. In addition, reduced glomerular filtration rate and alterations in sodium transport at other tubular sites can reduce the natriuretic effect of delivered drug. To use diuretics effectively in CKD, clinicians must understand these changes in diuretic pharmacokinetics and pharmacodynamics. This chapter reviews the sites and mechanisms of action of diuretics, describes how diuretic pharmacologic characteristics are affected by CKD, and details how best to overcome diuretic resistance. Much of the focus is on the loop agents, which are the most potent class of diuretics and the mainstay of treatment in CKD patients. As increasing attention is being paid to the role of thiazides and mineralocorticoid antagonists, the use of other classes of diuretics is also covered, as is the use of diuretics to treat specific subsets of CKD patients.
