Loop diuretics complications

Although amiloride may reduce the renal clearance of lithium, it appears to be free of the troublesome interaction with lithium that complicates the use of thiazides and loop diuretics. 

Dose and length of therapy with loop diuretics may predict the likelihood of developing calcium deposits in the renal parenchyma. Ten premature infants developed nephrocalcinosis after receiving furosemide at a dose of at least 2 mg/kg per day for 12 days [102]. In a study by Saarela et al, infants who developed renal calcifications were receiving higher daily doses of furosemide than infants who had not developed this complication (1.9 + 0.6 vs. 1.3 + 0.4 mg/kg per day p value-0.01) [104]. Calcifications were diagnosed within a few months of initiating furosemide. 

Volume resuscitation is the cornerstone of management of lithium toxicity (Table 3) [124, 125]. Patients with underlying lithium-induced diabetes insipidus may initially present with volume depletion. It must be borne in mind, however, that hypernatremia [125] is a potential complication, especially in those with underlying diabetes insipidus. Forced saline diuresis is expected to increase lithium clearance by decreasing proximal tubular reabsorption. With normal renal function, lithium can be cleared at a rate of 10-40 mL/min [125]. The excretion of lithium can be further increased acutely by using acetazolamide and/or loop diuretics [124,125]. 

Toxicity Loop diuretics usually induce hypokalemic metabolic alkalosis. Because large amounts of sodium are presented to the collecting tubules, wasting of potassium (which is excreted by the kidney in an effort to conserve sodium) may be severe. Because they are so efficacious, the loop diuretics can cause hypovolemia and cardiovascular complications. Ototoxicity is an important toxic effect of the loop agents. The sulfonamides in this group may cause typical sulfonamide allergy. 

Because mannitol will pull fluid off the brain by osmosis into the circulatory system it can lead to a circulatory overload, which the heart could not handle because the cKent already has CHE This client would need an order for a loop diuretic to prevent serious cardiac complications. 

Acutely, the use of saline infusion accompanied by administration of loop diuretics enhances urinary calcium excretion. Calcitonin, mithramycin and corticosteroids decrease calcium movement from bone. Reduced intake of calcium and corticosteroids decrease intestinal absorption of calcium. Short-term hemodialysis or peritoneal dialysis is effective for the rapid removal of calcium from the blood in crisis situations, especially in patients with renal failure or congestive heart failure. Prolonged hemodialysis, however, is not a therapeutic solution because of its impracticality and high complication rate. 

The mercurial diuretics essentially contain in an organic molecule. They usually inhibit sodium reabsorption in the proximal tubuler and ascending loop of Henle. There may be slight effect in the distal tubule where inhibition of chloride reabsorption also occurs. The mercurials have been foimd to enhance excretion though potassium loss is less than that produced by many other diuretics. However, the overall action of mercurial diuretics is invariably increased by acidification of urine. The mercurial diuretics are not very much used in clinical practices due to their pronormced and marked side-effects viz., mercurialism, hypersensitivity and excessive diuresis which may lead to electrolyte depletion and vascular complications. Most of the mercurials are administered by intramuscular route and the availability of orally active diru etics has limited their use. 

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