Furosemide stress test and interstitial fibrosis in kidney biopsies in chronic kidney disease

Jesús Rivero, Francisco Rodríguez, Virgilia Soto, Etienne Macedo, Lakhmir S Chawla, Ravindra L Mehta, Sucheta Vaingankar, Pranav S Garimella, Carlos Garza, Magdalena Madero, Jesús Rivero, Francisco Rodríguez, Virgilia Soto, Etienne Macedo, Lakhmir S Chawla, Ravindra L Mehta, Sucheta Vaingankar, Pranav S Garimella, Carlos Garza, Magdalena Madero

Abstract

Background: Interstitial fibrosis (IF) on kidney biopsy is one of the most potent risk factors for kidney disease progression. The furosemide stress test (FST) is a validated tool that predicts the severity of acute kidney injury (especially at 2 h) in critically ill patients. Since furosemide is secreted through the kidney tubules, the response to FST represents the tubular secretory capacity. To our knowledge there is no data on the correlation between functional tubular capacity assessed by the FST with IF on kidney biopsies from patients with chronic kidney disease (CKD). The aim of this study was to determine the association between urine output (UO), Furosemide Excreted Mass (FEM) and IF on kidney biopsies after a FST.

Methods: This study included 84 patients who underwent kidney biopsy for clinical indications and a FST. The percentage of fibrosis was determined by morphometry technique and reviewed by a nephropathologist. All patients underwent a FST prior to the biopsy. Urine volume and urinary sodium were measured in addition to urine concentrations of furosemide at different times (2, 4 and 6 h). We used an established equation to determine the FEM. Values were expressed as mean, standard deviation or percentage and Pearson Correlation.

Results: The mean age of the participants was 38 years and 44% were male. The prevalence of diabetes mellitus, hypertension and diuretic use was significantly higher with more advanced degree of fibrosis. Nephrotic syndrome and acute kidney graft dysfunction were the most frequent indications for biopsy. eGFR was inversely related to the degree of fibrosis. Subjects with the highest degree of fibrosis (grade 3) showed a significant lower UO at first hour of the FST when compared to lower degrees of fibrosis (p = 0.015). Likewise, the total UO and the FEM was progressively lower with higher degrees of fibrosis. An inversely linear correlation between FEM and the degree of fibrosis (r = - 0.245, p = 0.02) was observed.

Conclusions: Our findings indicate that interstitial fibrosis correlates with total urine output and FEM. Further studies are needed to determine if UO and FST could be a non-invasive tool to evaluate interstitial fibrosis.

Trial registration: ClinicalTrials.gov NCT02417883.

Keywords: Furosemide stress test; Interstitial fibrosis; Kidney biopsy; Uresis.

Conflict of interest statement

Pranav S Garimella is a member of the editorial board for BMC Nephrology.

Figures

Fig. 1
Fig. 1
Patients Flow Diagram
Fig. 2
Fig. 2
Furosemide Stress Test Procedure
Fig. 3
Fig. 3
Correlation analysis of interstitial fibrosis and FEM
Fig. 4
Fig. 4
a and b FEM2, fibrosis score and baseline eGFR

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