Meta-Analysis
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Crit Care Med. May 9, 2022; 11(3): 178-191
Published online May 9, 2022. doi: 10.5492/wjccm.v11.i3.178
Diuretic combinations in critically ill patients with respiratory failure: A systematic review and meta-analysis
Jean Maxime Côté, Nadir Goulamhoussen, Blaithin A McMahon, Patrick T Murray
Jean Maxime Côté, Nadir Goulamhoussen, Division of Nephrology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, Montréal H2X0C1, Québec, Canada
Blaithin A McMahon, Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, SC 29425, United States
Patrick T Murray, Department of Medicine, School of Medicine, University College Dublin, Dublin D078NN, Ireland
Author contributions: Côté JM, Goulamhoussen N, McMahon BA and Murray PT designed the research study and methodology; Côté JM and Goulamhoussen N performed the research and analyzed the data; Côté JM wrote the draft manuscript; all authors reviewed and approved the final manuscript.
Conflict-of-interest statement: No potential conflict of interest relevant to this article was reported.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Jean Maxime Côté, FRCP (C), MD, MSc, Consultant Physician, Division of Nephrology, Department of Medicine, Centre Hospitalier de l'Université de Montréal, CHUM 1000 St Denis, Montréal H2X0C1, Québec, Canada. jean-maxime.cote@umontreal.ca
Received: January 12, 2022
Peer-review started: January 12, 2022
First decision: February 8, 2022
Revised: February 11, 2022
Accepted: April 24, 2022
Article in press: April 24, 2022
Published online: May 9, 2022
ARTICLE HIGHLIGHTS
Research background

Diuretics are essential to maintain fluid balance in patients admitted to intensive care units (ICUs). However, resistance to loop-diuretics is common and diuretic combinations are often used in order to mitigate this resistance.

Research motivation

As opposed to patients with heart failure where combinations of different classes of diuretics have been extensively studied and are now recommended, the body of evidence regarding diuretic combinations in ICU patients with hypoxemic respiratory failure is scarce.

Research objectives

This study systematically reviewed the efficacy and safety of common diuretics combinations in ICU patients with respiratory failure when compared to loop-diuretics in monotherapy.

Research methods

A systematic review and meta-analysis were performed. A pooled analysis of the mean difference for the 24-h urine output and the 24-h fluid balance between loop-diuretics in monotherapy and common diuretics combinations (thiazides, carbonic anhydrase inhibitors and mineralocorticoid antagonists) was performed. Descriptive statistics were used to report the occurrence of safety events, such as electrolyte disturbances, hypotension and acute kidney injury.

Research results

From 6510 citations, nine studies totalling 440 patients were included. When compared to loop diuretics alone, the addition of a second diuretic is associated with an improved negative fluid balance at 24 h mean differences (MD) of -1.06 L [95% confidence interval (CI): -1.46; -0.65], mainly driven by the combination of a thiazide plus furosemide [MD: -1.25 L (95%CI: -1.68; -0.82)]. The heterogeneity on the report of clinical and safety endpoints was high, but electrolytes anomalies were frequent and confirms the need for additional monitoring when prescribing such combinations.

Research conclusions

Larger trials are required to confirm the efficacy and safety of diuretic combinations in this population. However, based on limited evidence the combination of thiazide plus loop-diuretics is associated with an increase in urine output and negative fluid balance.

Research perspectives

The study has highlighted the paucity of data on the optimal strategy to optimise fluid balance in patients with respiratory failure and relative diuretics resistance.