Development and standardization of a furosemide stress test to predict the severity of acute kidney injury

Lakhmir S Chawla, Danielle L Davison, Ermira Brasha-Mitchell, Jay L Koyner, John M Arthur, Andrew D Shaw, James A Tumlin, Sharon A Trevino, Paul L Kimmel, Michael G Seneff, Lakhmir S Chawla, Danielle L Davison, Ermira Brasha-Mitchell, Jay L Koyner, John M Arthur, Andrew D Shaw, James A Tumlin, Sharon A Trevino, Paul L Kimmel, Michael G Seneff

Abstract

Introduction: In the setting of early acute kidney injury (AKI), no test has been shown to definitively predict the progression to more severe stages.

Methods: We investigated the ability of a furosemide stress test (FST) (one-time dose of 1.0 or 1.5 mg/kg depending on prior furosemide-exposure) to predict the development of AKIN Stage-III in 2 cohorts of critically ill subjects with early AKI. Cohort 1 was a retrospective cohort who received a FST in the setting of AKI in critically ill patients as part of Southern AKI Network. Cohort 2 was a prospective multicenter group of critically ill patients who received their FST in the setting of early AKI.

Results: We studied 77 subjects; 23 from cohort 1 and 54 from cohort 2; 25 (32.4%) met the primary endpoint of progression to AKIN-III. Subjects with progressive AKI had significantly lower urine output following FST in each of the first 6 hours (p<0.001). The area under the receiver operator characteristic curves for the total urine output over the first 2 hours following FST to predict progression to AKIN-III was 0.87 (p = 0.001). The ideal-cutoff for predicting AKI progression during the first 2 hours following FST was a urine volume of less than 200mls(100ml/hr) with a sensitivity of 87.1% and specificity 84.1%.

Conclusions: The FST in subjects with early AKI serves as a novel assessment of tubular function with robust predictive capacity to identify those patients with severe and progressive AKI. Future studies to validate these findings are warranted.

Figures

Figure 1
Figure 1
Patient flow. eGFR, estimated glomerular filtration rate; FeNa, fractional excretion of sodium; AKIN, Acute Kidney Injury Network.
Figure 2
Figure 2
Urinary output in response to furosemide stress test.

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