Renal failure metolazone

Fluid overload occurs commonly in patients with renal failure, often in the absence of associated heart disease. If salt and water intake is not controlled in the patient who is oliguric or anaemic, plasma volume and symptoms of congestive heart failure ensue. Hypertension and coronary heart disease with increasing age contributes to the congestive heart failure. Diuretics like loop-diuretics or metolazone may be of value. Digitalis should be used with caution in patients on dialysis as cardiac arrhythmias may ensue in patients receiving dialysis in the presence of hypokalemia. 

Metolazone Metolazone [me TOLE a zone] is more potent than the thiazides and, unlike the thiazides, causes Na+ excretion in advanced renal failure. 

Hogg KJ, Hillis WS. Captopril/metolazone induced renal failure. Lancet 1986 l(8479) 501-2. 

THERAPEUTIC USES Thiazide diuretics are used to treat edema associated with heart (congestive heart failure), liver (cirrhosis), and renal (nephrotic syndrome, chronic renal failure, and acute glomerulonephritis) disease. With the possible exceptions of metolazone and indapamide, most thiazide diuretics are ineffective when the GFR is <30-40 mL/min. 

Acute, fatal, renal failure developed in 2 patients with cardiac failure within 4 weeks of being treated with enalapril and furosemide, and in 2 similar patients renal impairment developed over a longer period. Reversible renal failure developed in a patient with congestive heart failure when captopril and metolazone were given. ... 

Acute renal failure was reported in a 35-year-old woman with systemic lupus erythematosus taking four capsules daily of a cat s claw product (species unspecified) for an unspecified length of time. The woman was also taking other medications including prednisone, atenolol, metolazone, furosemide, and nifedipine. Biochemical parameters for renal function were reported to return to normal after cessation of the cat s claw product (Hilepo et al. 1997). 

A 78-year-old man became short of breath. He had been taking rosiglitazone 8 mg/day for 6 months. He had renal insufficiency, atrial fibrillation, hypertension, and congestive heart failure, with pitting edema and bilateral pleural effusions. He was refractory to intravenous furosemide and metolazone. Withdrawal of rosiglitazone and administration of bumetanide gave a net fluid output of 9.5 litres and the edema resolved. 

Metolazone occupies an intermediate position between the thiazide diuretics and the more potent loop diuretics (1). It is more effective than the thiazides in moderate to advanced renal insufficiency (SED-8, 488) (SED-9, 355). In patients with normal renal function its antihypertensive effect compares favorably with that of bendroflumethia-zide. When severe heart failure is refractory to conventional triple therapy (high-dose loop diuretic, digoxin, and angiotensin-converting enzyme inhibitor) metolazone can restore diuresis, with weight loss and clinical improvement. 

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