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Ravindra L. Mehta, MD; Maria T. Pascual, RN, MPH; Sharon Soroko, MS; Glenn M. Chertow, MD, MPH; for the PICARD Study Group

JAMA. 2002;288:2547-2553.

Context  Acute renal failure is associated with high mortality and morbidity. Diuretic agents continue to be used in this setting despite a lack of evidence supporting their benefit.

Objective  To determine whether the use of diuretics is associated with adverse or favorable outcomes in critically ill patients with acute renal failure.

Design  Cohort study conducted from October 1989 to September 1995.

Patients and Setting  A total of 552 patients with acute renal failure in intensive care units at 4 academic medical centers affiliated with the University of California. Patients were categorized by the use of diuretics on the day of nephrology consultation and, in companion analyses, by diuretic use at any time during the first week following consultation.

Main Outcome Measures  All-cause hospital mortality, nonrecovery of renal function, and the combined outcome of death or nonrecovery.

Results  Diuretics were used in 326 patients (59%) at the time of nephrology consultation. Patients treated with diuretics on or before the day of consultation were older and more likely to have a history of congestive heart failure, nephrotoxic (rather than ischemic or multifactorial) origin of acute renal failure, acute respiratory failure, and lower serum urea nitrogen concentrations. With adjustment for relevant covariates and propensity scores, diuretic use was associated with a significant increase in the risk of death or nonrecovery of renal function (odds ratio, 1.77; 95% confidence interval, 1.14-2.76). The risk was magnified (odds ratio, 3.12; 95% confidence interval, 1.73-5.62) when patients who died within the first week following consultation were excluded. The increased risk was borne largely by patients who were relatively unresponsive to diuretics.

Conclusions  The use of diuretics in critically ill patients with acute renal failure was associated with an increased risk of death and nonrecovery of renal function. Although observational data prohibit causal inference, it is unlikely that diuretics afford any material benefit in this clinical setting. In the absence of compelling contradictory data from a randomized, blinded clinical trial, the widespread use of diuretics in critically ill patients with acute renal failure should be discouraged.

Author Affiliations: Division of Nephrology, University of California, San Diego, Medical Center (Dr Mehta and Mss Pascual and Soroko); and Divisions of Nephrology, Moffitt-Long Hospitals and UCSF–Mt Zion Medical Center, University of California, San Francisco (Dr Chertow).

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