Diuretic prescriptions in the first year of hemodialysis: International practice patterns and associations with outcomes

The use of diuretics in patients on hemodialysis (HD) is thought to maintain diuresis. However, this assumption and the optimal dose are based on little scientific evidence, and associations with clinical outcomes are unclear. We reported international variation in diuretic use and loop diuretic dose across 27 759 HD patients with dialysis vintage < 1 year in the Dialysis Outcomes and Practice Patterns Study (DOPPS) phases 2–5 (2002–2015), a prospective cohort study. Doses of torsemide (4:1) and bumetanide (80:1) were converted to oral furosemide-equivalent dose. Adjusted Cox, logistic, and linear regressions were used to investigate the association of diuretic use and dose with outcomes. Diuretic utilization varied widely by country at vintage < 3 months, ranging from > 80% in Germany and Sweden to < 35% in the US, at a median dose ranging from 400-500 mg/day in Germany and Sweden to <100 mg/day in Japan and the US. Neither diuretic use nor higher doses were associated with a lower risk of all-cause mortality, or a higher risk of hospitalization for fracture, or elevated PTH levels, but the prescription of higher doses (>200 mg/day) was associated with a higher risk of all-cause hospitalization. Substantial international differences exist in diuretic prescription, with usage and doses much higher in some European countries than the US. The prescription and higher doses of loop diuretics was not associated with improved outcomes.