What role do diuretics play in the management of renal failure in patients with liver disease?

In patients with liver disease complicated by renal failure, diuretics play a critical role in managing fluid overload, a common and challenging clinical issue due to the interplay of portal hypertension, hypoalbuminaemia, and renal hypoperfusion. Diuretics, particularly loop diuretics, are used to promote sodium and water excretion to relieve symptoms of fluid retention such as ascites and peripheral oedema, which are frequent in this population. However, their use must be carefully balanced against the risk of worsening renal function, as these patients often have compromised renal perfusion and are at risk of acute kidney injury.

Loop diuretics are typically the first-line agents to control sodium and water retention in liver disease with renal impairment, aiming to reduce extracellular fluid volume and improve symptoms. The dose should be titrated cautiously, monitoring renal function, electrolytes, and urine output closely to avoid precipitating or exacerbating renal failure. In cases where loop diuretics alone are insufficient, combination therapy with aldosterone antagonists (mineralocorticoid receptor antagonists) may be considered, as these target the hyperaldosteronism commonly seen in cirrhosis-related fluid retention.

It is essential to recognize that diuretic therapy in this context requires specialist input due to the delicate balance between managing fluid overload and preserving renal function. Temporary cessation or dose adjustment of other nephrotoxic or renally excreted drugs, such as ACE inhibitors or ARBs, may be necessary during episodes of acute kidney injury. Additionally, non-pharmacological measures and close monitoring are integral to management.

Recent literature emphasizes the importance of individualized diuretic regimens and highlights the risk of diuretic resistance in advanced liver disease with renal failure, suggesting that ultrafiltration or other interventions may be required if diuretics fail to achieve adequate fluid removal (Novak and Ellison, 2022). Nonetheless, UK guidelines prioritize cautious diuretic use with vigilant monitoring to optimize symptom control while minimizing renal harm ¹,³.