Guidelines for use of diuretics: a view from a member of JNC 7

Effect of the combination of bumetanide plus chlorthalidone on hypertension and volume overload in patients with chronic kidney disease stage 4-5 KDIGO without renal replacement therapy: a double-blind randomized HEBE-CKD trial

Background

The co-administration of loop diuretics with thiazide diuretics is a therapeutic strategy in patients with hypertension and volume overload. The aim of this study was to assess the efficacy and safety of treatment with bumetanide plus chlorthalidone in patients with chronic kidney disease (CKD) stage 4–5 KDIGO.

Methods

A double-blind randomized study was conducted. Patients were randomized into two groups: bumetanide plus chlorthalidone group (intervention) and the bumetanide plus placebo group (control) to evaluate differences in TBW, ECW and ECW/TBW between baseline and 30 Days of follow-up. Volume overload was defined as ‘bioelectrical impedance analysis as fluid volume above the 90th percentile of a presumed healthy reference population. The study’s registration number was NCT03923933.

Results

Thirty-two patients with a mean age of 57.2 ± 9.34 years and a median estimated glomerular filtration rate (eGFR) of 16.7 ml/min/1.73 m² (2.2–29) were included. There was decreased volume overload in the liters of total body water (TBW) on Day 7 (intervention: -2.5 vs. control: -0.59, p = 0.003) and Day 30 (intervention: -5.3 vs. control: -0.07, p = 0.016); and in liters of extracellular water (ECW) on Day 7 (intervention: -1.58 vs. control: -0.43, p < 0.001) and Day 30 (intervention: -3.05 vs. control: -0.15, p < 0.000). There was also a decrease in systolic blood pressure on Day 7 (intervention: -18 vs. control: -7.5, p = 0.073) and Day 30 (intervention: -26.1 vs. control: -10, p = 0.028) and in diastolic blood pressure on Day 7 (intervention: -8.5 vs. control: -2.25, p = 0.059) and Day 30 (intervention: -13.5 vs. control: -3.4, p = 0.018).

Conclusion

In CKD stage 4–5 KDIGO without renal replacement therapy, bumetanide in combination with chlorthalidone is more effective in treating volume overload and hypertension than bumetanide with placebo.

Diuretic and Anti-Inflammatory Activities of the Microencapsulated Acrocomia aculeata (Arecaceae) Oil on Wistar Rats

Acrocomia aculeata, popularly known as "bocaiuva," is widely acknowledged in culinary and traditional medicines to treat cardiovascular diseases, a combined effect with diuretics that are also used for hypertension. However, there are no scientific data published to support its use as functional food and its ethnopharmacological use. This study intended to determine the composition of fatty acids of the pulp oil and evaluate the diuretic action and anti-inflammatory activity of the in natura and microencapsulated oil orally administrated on rats. The obtained results confirm the prevalence of monounsaturated fatty acids (68.51%), especially oleic acid (65.68%±1.05%), in the oil from the bocaiuva pulp. The in natura A. aculeata oil has diuretic (P<.01) and anti-inflammatory potential, which promoted a marked inhibition on the hind paw edema induced by carrageenan (67%±7% after 2 h) (P<.01). In addition, results show that the oral administration of the bocaiuva oil at 300 (P<.05) and 700 (P<.05) mg/kg doses significantly inhibited the leukocyte migration induced by carrageenan to the pleural cavity in rats. The inhibitions equaled 91%±3% and 81%±16%, respectively. The microencapsulated oil also showed antiedematogenic (P<.01) as well as diuretic activities (P<.01). The microencapsulation by complex coacervation was shown to be a technique that favors the bioavailability and preservation of bioactive components of the bocaiuva oil.

Which thiazide to choose as add-on therapy for hypertension?

Combined therapy is required in the majority of patients with hypertension to achieve blood pressure (BP) targets. Although different antihypertensive drugs can be combined, not all combinations are equally effective and safe. In this context, the combination of a renin angiotensin system inhibitor with a diuretic, usually a thiazide, particularly hydrochlorothiazide (HCTZ) or thiazide-like diuretics, such as chlorthalidone or indapamide, is recommended. However, not all diuretics are equal. Although HCTZ, chlorthalidone, and indapamide as add-on therapy effectively reduce BP levels, the majority of studies have obtained greater BP reductions with chlorthalidone or indapamide than with HCTZ. Moreover, there are data showing benefits with chlorthalidone or indapamide beyond BP. Thus, chlorthalidone seems to have pleiotropic effects beyond BP reduction. Moreover, compared with placebo, chlorthalidone has small effects on fasting glucose and total cholesterol, and compared with HCTZ, chlorthalidone achieves significantly lower total cholesterol and low-density lipoprotein cholesterol levels. Similarly, indapamide has demonstrated no negative impact on glucose or lipid metabolism. More importantly, although head-to-head clinical trials comparing the effects of indapamide or chlorthalidone with HCTZ are not available, indirect comparisons and post hoc analyses suggest that the use of chlorthalidone or indapamide is associated with a reduction in cardiovascular events. Despite this, the most frequent diuretic used in clinical practice as add-on therapy for hypertension is HCTZ. The purpose of this review is to update the published data on the efficacy and safety of HCTZ, chlorthalidone, and indapamide as add-on therapy in patients with hypertension.

Diuretic and antilithiasic activities of ethanolic extract from Piper amalago (Piperaceae)

OBJECTIVE

Piper amalago is used in Brazilian folk medicine as diuretic and for the treatment of urinary calculus disease, although no scientific data have been described to support these effects. Thus, this study aims to evaluate the diuretic effects and antilithiatic activity of the ethanolic extract of P. amalago (EEPam).

MATERIALS AND METHODS

Ethanolic extracts of P. amalago (125, 250 and 500mg/kg) were orally administered in male Wistar rats (n=5) and urinary excretion was measured at intervals of up to 24h after administration. The antilithiasic effect of EEPam on calcium oxalate urolithiasis crystallization was examined in a turbidimetric model.

RESULTS

The oral administration of all doses of EEPam significantly increased urine output after 24h when compared to control group. Moreover, the application of EEPam, induced an inhibitory effect on calcium oxalate crystallization.

CONCLUSIONS

According to results, P. amalago extracts showed diuretic and natriuretic activity and antilithiasic effects.