Loop diuretics
AMT in HFrEF · Class IAMT in HFpEF · Class IRemoval by dialysis
What each drug's prescribing information says about removal by (haemo)dialysis. Where the label is silent, this page says so rather than inferring from protein binding.
- FurosemideNot removed (or not meaningfully removed)
“Hemodialysis does not accelerate furosemide elimination.”
- TorsemideNot removed (or not meaningfully removed)
“Torsemide is not dialyzable, so hemodialysis will not accelerate elimination.”
- BumetanideLabel does not address dialysis removal
The bumetanide label contains no statement on dialysis.
After starting: what a change in creatinine, eGFR or potassium means
Rising creatinine: check for hypovolaemia, stop nephrotoxins, withhold an MRA if eGFR falls below 20, and stop a concomitant thiazide. Small transient creatinine rises during effective decongestion are not associated with poor outcome.
“Check for hypovolaemia/dehydration.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 17, Table S7 Source“Withhold an MRA (if eGFR drops below 20 mL/min/1.73 m2).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 17, Table S7 Source“Possible worsening kidney function should be evaluated in the context of diuretic response, because small and transient rises in serum creatinine during diuretic therapy are not associated with poor outcome if decongestion is achieved.”
A hemodynamic eGFR dip of up to 30% after starting an SGLT2 inhibitor, RAAS inhibitor, MRA or ARNI is expected and should not lead to discontinuation; above 30%, look for other causes of AKI (KDIGO). ESC accepts a creatinine rise of less than 50% above baseline as long as eGFR stays above 15.
“Hemodynamic fluctuations in eGFR up to 30% can be seen and should not lead to discontinuation”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 10“If >30%, other causes of AKI should be evaluated”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 10“An increase in serum creatinine of <50% above baseline, as long as eGFR remains >15 mL/min/1.73 m2, is considered acceptable.”
2026 ESC Guidelines for the diagnosis and treatment of heart failure (2026)· p. 66, Section 10.3 Source“Worsening kidney function alone is not an independent determinant of outcomes in patients with acute HF.”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 11
Drugs and doses
| Drug | Brands | Start | Target | Kidney dosing |
|---|---|---|---|---|
| Furosemide | Lasix, Furoscix (s.c.), Lasix ONYU (s.c.) | 20-40 mg oral (ESC Table S7); i.v. 40 mg if diuretic-naive, 2x usual oral daily dose if chronic user (ESC Figure 15) | Lowest dose that maintains euvolaemia; usual 40-240 mg/day; label oral maximum 600 mg/day; ESC i.v. ceiling 600 mg/day (up to 1000 mg/day with severely impaired kidney function) | No eGFR-based dose reduction; higher doses needed as eGFR falls. Contraindicated in anuria. Ototoxicity risk higher with rapid injection, severe renal impairment and high doses: give high i.v. doses as an infusion not exceeding 4 mg/min. Not removed by haemodialysis. |
| Torsemide (torasemide) | Demadex, Soaanz | 5-10 mg (ESC Table S7); label: HF 10-20 mg once daily, chronic renal failure 20 mg once daily | Usual 10-20 mg/day (ESC); titrate by doubling; doses above 200 mg not adequately studied (label) | Label gives a specific chronic-renal-failure starting dose (20 mg) with doubling to 200 mg. Contraindicated in anuria. Not dialyzable. Renal clearance falls in renal failure but total plasma clearance is unchanged; less drug reaches the tubular site of action. |
| Bumetanide | Bumex | 0.5-1.0 mg (ESC Table S7); label usual total daily oral dose 0.5-2 mg | Usual 1-5 mg/day (ESC); label maximum 10 mg/day | Can be used to induce diuresis in renal insufficiency; stop if BUN/creatinine rise markedly or oliguria develops in progressive renal disease. Contraindicated in anuria. Ototoxicity risk with high, frequently repeated i.v. doses when renal excretion is impaired. |
Status by kidney stage
| Stage | Initiate | Continue |
|---|---|---|
| G1 | Recommended Class I for patients with congestion/volume overload, at the lowest dose that maintains euvolaemia; not indicated without congestion. | Recommended Continue with dynamic dosing according to volume status; reduce when euvolaemic. |
| G2 | Recommended Class I for congestion; same dosing as G1. | Recommended Continue with dynamic dosing; recheck chemistry 1-2 weeks after start or dose increase. |
| G3a | Recommended Class I for congestion; ESC CVD-CKD guideline gives a Class I recommendation in HF with CKD; somewhat higher doses may be needed. | Recommended Continue; dose up or down by volume status, with higher doses needed as eGFR falls. |
| G3b | Recommended Class I for congestion; diuretic response is reduced, so higher doses are usually needed (ESC CVD-CKD Figure 10: 120 mg i.v. furosemide-equivalent at eGFR 30-44 in DHF). | Recommended Continue; transient creatinine rises with good decongestion are not a reason to stop. |
| G4 | Use with caution Still indicated for congestion (ESC/KDIGO: use irrespective of eGFR), but ESC lists eGFR <30 as a caution/seek-specialist-advice situation; expect higher dose needs and watch for ototoxicity at high doses. | Use with caution Continue at the dose needed for euvolaemia with closer monitoring; stop if azotemia and oliguria progress (label). |
| G5 | Use with caution May be used while urine output persists, at high doses; contraindicated once anuric. Ototoxicity risk is highest here. | Use with caution Continue while there is a diuretic response; stop in anuria or if azotemia and oliguria progress; consider kidney replacement therapy for refractory overload. |
| dialysis | Use with caution No guideline recommendation; only reasonable in patients with meaningful residual urine output (contraindicated if anuric). Torsemide label: up to 200 mg/day did not change steady-state fluid retention in haemodialysis-requiring renal failure. | Use with caution Continuing a loop diuretic at haemodialysis start in patients with residual urine output was associated with fewer hospitalizations, less intradialytic hypotension and lower interdialytic weight gain (observational); stop when anuric. |
| aki | Use with caution Use only to treat volume overload (KDIGO AKI); in congested HF a creatinine rise during effective decongestion (pseudo-WRF) is not AKI and should not stop therapy. | Use with caution Continue decongestion if diuretic response is good despite creatinine rise up to 50% (ESC CVD-CKD Class I); reduce/stop if hypovolaemic, or if azotemia and oliguria progress. |
| transplant | Allowed No transplant-specific restriction found. | Allowed Same. |
Cutoffs recorded from the sources
- egfr < 30 mL/min/1.73m2 → caution (initiate; furosemide, torsemide, bumetanide)“Significant renal dysfunction (eGFR <30 mL/min/1.73 m2)—may be made worse by diuretic or patient may not respond to diuretic (especially” — esc2026-supp, p. 16
- potassium <= 3.5 mmol/L → caution (initiate; furosemide, torsemide, bumetanide)“Significant hypokalaemia (K+ ≤3.5 mmol/L)—may be made worse by diuretic.” — esc2026-supp, p. 16
- sbp < 90 mmHg → caution (initiate; furosemide, torsemide, bumetanide)“Symptomatic or severe asymptomatic hypotension (systolic blood pressure <90 mmHg)—may be made worse by diuretic-induced hypovolaemia.” — esc2026-supp, p. 16
- creatinine_rise_pct <= 50 % above baseline → recommended (continue decongestion if good diuretic response; DHF + CKD not on KRT) (continue; furosemide, torsemide, bumetanide)“Continuation of decongestive therapy is recommended in congested patients with decompensated HF and CKD (not on KRT) who exhibit good diuretic response despite a rise in creatinine (up to 50%) to help achieve and” — esc2026-ckd, p. 44
- creatinine_rise_pct > 50 % above baseline → caution (re-evaluate decongestive therapy) (hold; furosemide, torsemide, bumetanide)“CAUTION IN CASE OF >50% increase in serum creatinine or absolute serum creatinine increases above >300 μmol/L” — esc2026-ckd, p. 45
- creatinine_abs > 300 umol/L → caution (re-evaluate decongestive therapy) (hold; furosemide, torsemide, bumetanide)“CAUTION IN CASE OF >50% increase in serum creatinine or absolute serum creatinine increases above >300 μmol/L” — esc2026-ckd, p. 45
- other <= 600 mg/day i.v. furosemide (up to 1000 mg/day with severely impaired kidney function) → dose ceiling (uptitrate; furosemide)“The highest daily dose for i.v. loop diuretics is generally considered furosemide 600 mg, although up to 1000 mg may be considered in patients with severely impaired kidney function.” — esc2026, p. 49
- other <= 600 mg/day oral furosemide → dose ceiling (uptitrate; furosemide)“The dose of LASIX may be carefully titrated up to 600 mg/day in patients with clinically severe edematous states.” — fda-furosemide, DOSAGE AND ADMINISTRATION
- other <= 200 mg/day torsemide → doses above not adequately studied (uptitrate; torsemide)“If the diuretic response is inadequate, titrate upward by approximately doubling until the desired diuretic response is obtained. Doses higher than 200 mg have not been adequately studied.” — fda-torsemide, 2.1 Treatment of Edema
- other <= 10 mg/day bumetanide → dose ceiling (uptitrate; bumetanide)“If the diuretic response to an initial dose of Bumex tablets is not adequate, in view of its rapid onset and short duration of action, a second or third dose may be given at 4- to 5-hour intervals up to a maximum daily dose of 10 mg.” — fda-bumetanide, DOSAGE AND ADMINISTRATION
- other <= 4 mg/min → high-dose parenteral therapy as controlled infusion (ototoxicity) (uptitrate; furosemide)“If the physician elects to use high-dose parenteral therapy, controlled intravenous infusion is advisable (for adults, an infusion rate not exceeding 4 mg furosemide per minute has been used)” — fda-furosemide-injection, 5.3 Ototoxicity
- other = 40 mg i.v. furosemide (higher if CKD) → starting dose (initiate; furosemide)“Start i.v. loop diuretic (40 mg furosemide in diuretic naive or double daily oral dose in chronic users)” — esc2026, p. 49
- other = 2 x usual oral daily dose → starting dose (initiate; furosemide, torsemide, bumetanide)“Patients naïve to diuretics usually respond well to 40 mg of i.v. furosemide or equivalent, whereas i.v. doses of two times the patient's usual oral diuretic dose should be considered for patients who have been on loop diuretics as outpatients.” — esc2026, p. 48
- other = 2.5 x daily home loop diuretic dose → may be considered (initiate; furosemide, torsemide, bumetanide)“An initial intravenous diuretic dose equivalent to 2.5-times the daily home loop diuretic dose may” — esc2026-ckd, p. 42
- other > 40 mg i.v. furosemide-equivalent → should be considered (initiate; furosemide, torsemide, bumetanide)“An initial intravenous diuretic dose >40 mg of furosemide-equivalent should be considered in patients with DHF with fluid overload and CKD (not on KRT) who are diuretic-naive to achieve sufficient diuretic response.” — esc2026-ckd, p. 42
- egfr < 30 mL/min/1.73m2 → 160 mg i.v. furosemide-eq total daily dose (30-44: 120 mg; >=45: 80 mg) (initiate; furosemide, torsemide, bumetanide)“eGFR mL/min/1.73 m2 mg eq. IV furosemide (Class IIb) <30 30–44 ≥45 160 120 80” — esc2026-ckd, p. 41
- other < 70 mmol/L → insufficient response: double loop dose and/or add non-loop diuretic (uptitrate; furosemide, torsemide, bumetanide)“A satisfactory diuretic response can be defined as a uNa+ content ≥70 mEq/L at 2 h or by a urine output ≥100 mL/h during the first 6 h (Figure 15).” — esc2026, p. 48
- other < 100 mL/h → insufficient response: double loop dose and/or add non-loop diuretic (uptitrate; furosemide, torsemide, bumetanide)“If there is an insufficient diuretic response, the loop diuretic i.v. dose can be doubled and/or a non-loop diuretic added.” — esc2026, p. 48
- other < 3 L in first 24 h with persistent congestion → escalate on day 2 (uptitrate; furosemide, torsemide, bumetanide)“If diuresis remains <3 l and congestion persists, further diuretic escalation should be considered during the second day of treatment.” — esc2026, p. 49
Trial evidence (informational)
- Meta-analysis of diuretic RCTs (Faris 2002) · Chronic HFDeath, worsening HF, exercise capacity: Lower risk of death and WHF vs placebo; better exercise capacity vs active control (no adequately powered RCT of loop diuretics)“One meta-analysis has shown that in patients with HF, diuretics appear to reduce the risk of death and WHF compared with a placebo, and compared with an active control, diuretics improved exercise capacity.” — esc2026, p. 32
- TRANSFORM-HF · Patients discharged after HF hospitalization (n=2859)All-cause mortality, torsemide vs furosemide: 26.1% vs 26.2%; HR 1.02 (95% CI 0.89-1.18)“Death occurred in 373 of 1431 patients (26.1%) in the torsemide group and 374 of 1428 patients (26.2%) in the furosemide group (hazard ratio, 1.02 [95% CI, 0.89-1.18]).” — mentz2023, Abstract, Results
- TRANSFORM-HF (conclusion) · As aboveAll-cause mortality: Neutral; limited by loss to follow-up, crossover and nonadherence“Among patients discharged after hospitalization for heart failure, torsemide compared with furosemide did not result in a significant difference in all-cause mortality over 12 months. However, interpretation of these findings is limited by loss to follow-up and participant crossover and nonadherence.” — mentz2023, Abstract, Conclusions and Relevance
- DOSE-AHF · Acute decompensated HFPatient global symptom assessment: No difference between high- and low-dose furosemide (or bolus vs infusion)“In the DOSE-AHF trial, no difference in the primary efficacy outcome of patients' symptom global assessment was shown with a high-dose regimen compared with a low-dose regimen of furosemide.” — esc2026, p. 48
Acute kidney injury
KDIGO AKI advises against diuretics to prevent or treat AKI except for volume overload. In congested HF, ESC 2026 and ESC CVD-CKD treat creatinine rises during effective decongestion as acceptable (pseudo-WRF) and recommend continuing decongestion (Class I if good diuretic response, creatinine rise up to 50%). Labels: discontinue if azotemia and oliguria increase in severe progressive renal disease.
“3.4.1: We recommend not using diuretics to prevent AKI. (1B)”
KDIGO 2012 Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012;2:1-138 (2012)· p. 12 Source“Importantly, WRF occurring in the setting of a good diuretic response is a normal kidney response to decongestive therapy and is associated with better outcome (also termed pseudo-WRF).”
“The occurrence of WRF often triggers inappropriate discontinuation and dose reduction of loop diuretics, leading to incomplete decongestion.”
“Adverse CV outcomes are observed in patients with worsening kidney function and poor diuretic response, but not in patients with good diuretic response.”
Dialysis
No guideline recommends or forbids loop diuretics on maintenance dialysis. Labels contraindicate them in anuria; furosemide and torsemide are not removed by haemodialysis. With residual urine output, continuing a loop diuretic at haemodialysis start was linked to better intradialytic and hospitalization outcomes (observational). For diuretic-resistant HF, ESC 2026 and ESC CVD-CKD point to ultrafiltration or peritoneal dialysis.
Trials: Sibbel 2019 (loop diuretic continuation at HD start)
“However, in patients who fail to respond to diuretic-based strategies, kidney replacement therapies should be considered.”
“If volume overload persists despite maximal diuretic therapy and haemodynamic optimization, or if severe metabolic alterations occur, haemodialysis or peritoneal dialysis, including dedicated ultrafiltration is a treatment option.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 42 Source“continuation of loop diuretics was associated with lower hospitalization (adjusted incidence rate ratio, 0.93; 95% confidence interval, 0.89 to 0.98) and intradialytic hypotension (adjusted incidence rate ratio, 0.95; 95% confidence interval, 0.92 to 0.99) rates”
Sibbel S et al. Continuation of loop diuretics at hemodialysis initiation. Clin J Am Soc Nephrol 2019 (PMC6364527) (2019)· Abstract, Results Source“If using concomitant loop and thiazide diuretic, stop thiazide diuretic. • Consider reducing dose of ACE-I/ARB. • Consider haemofiltration/dialysis.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 17 Source“LASIX is contraindicated in patients with anuria and in patients with a history of hypersensitivity to furosemide.”
“Although loop diuretics are commonly used diuretics to improve volume overload in dialysis patients, the efficacy of loop diuretics is poor in anuric renal disease patients, and ototoxicity is common.”
Guo L et al. Management of Chronic Heart Failure in Dialysis Patients. Rev Cardiovasc Med 2024 (PMC11270084) (2024)· Section 4.5 Diuretics Source
Kidney transplant
No kidney-transplant-specific statement found in the HF, CKD or label sources; use eGFR-stage rules.
No verbatim statement found for this cell.
Albuminuria
Higher albuminuria is linked to diuretic resistance; KDIGO 2026 treats low eGFR or high urine ACR as a trigger for higher initial i.v. doses (at least 2.5x outpatient dose) and early adjunctive diuretics. Informational; not a separate matrix column.
“Furthermore, increased albuminuria is linked to diuretic resistance.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 40 Source“Initial i.v. dose should be at least 2.5 × higher than outpatient dose Even higher doses of loop diuretics may be needed (consider torsemide or bumetanide) Early initiation of adjunctive diuretics”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 13
Monitoring
Outpatient: check renal function and electrolytes before start and 1-2 weeks after start or any dose increase. Label: check electrolytes, CO2, creatinine and BUN often in the first months. In-hospital DHF: creatinine and electrolytes at least every 24 h, spot uNa at 2 h and urine output at 6 h to judge response.
“Re-check blood chemistry 1–2 weeks after an initiation and after any increase in dose (urea/BUN, creatinine, K+, Na+).”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 16 Source“Check frequently for hypotension/hypoperfusion. Check serum creatinine and electrolytese at least every 24 h”
“Serum electrolytes (particularly potassium), CO 2, creatinine and BUN should be determined frequently during the first few months of LASIX therapy and periodically thereafter.”
“For practical reasons, patients with (short-term) alterations in loop diuretic dose, including initiation, should be monitored closely with respect to renal function and electrolytes.”
Beldhuis 2022 Circulation: Evidence-based medical therapy in HFrEF patients with CKD (2022)· p. 13 Source
In-hospital initiation
i.v. loop diuretic for all DHF with fluid overload (Class I): 40 mg furosemide if naive (higher in CKD), 2x home oral dose if chronic user (ESC CVD-CKD/KDIGO: 2-2.5x); check uNa at 2 h and urine output at 6 h; double the dose if response is poor; repeat every 12 h; ceiling 600 mg/day (1000 mg in severe CKD). Bolus and infusion are equivalent; no loop diuretic is superior. Continue i.v. until decongested, then switch to oral.
“Intravenous loop diuretics are recommended for all patients with DHF admitted with fluid overload to improve symptoms”
“There is no evidence indicating differential outcomes with i.v. bolus administration compared to continuous infusion or that one loop diuretic is superior to another.”
“Intravenous diuretics should be continued until optimal decongestion is achieved; then, a switch to oral diuretics, if needed to maintain the volume status, is recommended.”
“For patients with decompensated HF and CKD, higher doses of loop diuretics and early combination diuretic therapy should be considered, as diuretic resistance increases with worsening CKD stage.”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 11 Source
Outpatient
Oral loop diuretic at the lowest dose that keeps the patient euvolaemic, adjusted to volume status (patients can self-adjust). For worsening HF: raise the oral dose, give a day-hospital i.v. infusion (3-6 h), or use subcutaneous furosemide at home. If response is poor, consider switching from furosemide to bumetanide or torsemide.
“In ambulatory patients with chronic HF showing signs of worsening, both i.v. diuretic administration and intensification of oral diuretic therapy can be considered.”
“Diuretic sessions usually consist of a 3–6 h i.v. diuretic infusion with dosing based on the patient's existing oral diuretic regimen.”
“The new formulations of diuretics (e.g. subcutaneous) might be particularly useful for home treatment.”
“Consider switching from furosemide to bumetanide or torasemide.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 17 Source
Where sources disagree
Initial i.v. loop dose in DHF for chronic users, especially with CKD
“Patients naïve to diuretics usually respond well to 40 mg of i.v. furosemide or equivalent, whereas i.v. doses of two times the patient's usual oral diuretic dose should be considered for patients who have been on loop diuretics as outpatients.”
“An initial intravenous diuretic dose equivalent to 2.5-times the daily home loop diuretic dose may”
2026 ESC Guidelines for the management of cardiovascular disease and chronic kidney disease, in collaboration with the ERA (2026)· p. 42 Source“Initial i.v. dose should be at least 2.5 × higher than outpatient dose Even higher doses of loop diuretics may be needed (consider torsemide or bumetanide) Early initiation of adjunctive diuretics”
Lam CSP, Bozkurt B, Cherney DZI, et al. Kidney Disease and Heart Failure: Recent Advances and Current Challenges. Conclusions From a Kidney Disease: Improving Global Outcomes (KDIGO) Controversies Conference. JACC: Heart Failure 2026 (KDIGO Executive Conclusions) (2026)· p. 13“The usual initial dose of furosemide is 20 mg to 40 mg given as a single-dose, injected intramuscularly or intravenously.”
Furosemide Injection, USP, prescribing information, Hospira, Inc. (2026)· 2.2 Recommended Dosage for Adults Source
Tool uses esc2026: Default to 2x home dose (ESC HF, Figure 15), with a CKD-specific option of 2.5x / eGFR-based dosing from ESC CVD-CKD (IIb). The label's 20-40 mg starting dose is written for diuretic-naive patients and does not cover chronic users; no conflict with the label ceiling.
Maximum daily loop dose
“The highest daily dose for i.v. loop diuretics is generally considered furosemide 600 mg, although up to 1000 mg may be considered in patients with severely impaired kidney function.”
“The dose of LASIX may be carefully titrated up to 600 mg/day in patients with clinically severe edematous states.”
“When administered as continuous infusion a dose of 0.5 mg/kg/ hour was not associated with ototoxicity.”
KDIGO 2012 Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl 2012;2:1-138 (2012)· p. 51 Source
Tool uses fda-furosemide: Label > guideline: default ceiling 600 mg/day; the ESC 1000 mg/day ceiling for severely impaired kidney function is shown as a guideline exception, with the label's ototoxicity warning (infusion not faster than 4 mg/min).
Choice of loop diuretic (torsemide/bumetanide vs furosemide)
“There is no evidence indicating differential outcomes with i.v. bolus administration compared to continuous infusion or that one loop diuretic is superior to another.”
“Consider switching from furosemide to bumetanide or torasemide.”
2026 ESC Guidelines for the management of heart failure: Supplementary data (Tables S1-S26) (2026)· p. 17 Source“There are insufficient data as to whether there are differences amongst loop diuretics (furosemide, bumetanide or torsemide) in relation to chronic changes in GFR.”
Tool uses esc2026: No outcome difference (TRANSFORM-HF neutral). Switching to the more bioavailable agents is a practical option for poor response, not a CKD-stage rule.
Open questions
- Dialysis: label anuria contraindication vs. observational benefit with residual urine output. Should the engine use 'caution' with a residual-urine-output prompt, or 'no-data'? (Set to 'caution' for now.)
- G4/G5: ESC Table S7 lists eGFR <30 as 'caution/seek specialist advice', while ESC CVD-CKD (Class I) and KDIGO 2026 support use at any eGFR. Kept as 'caution' (conservative).
- ESC CVD-CKD Figure 10 eGFR-based i.v. starting doses (80/120/160 mg): does the printed Class IIb label belong to the diuretic-naive eGFR table or the chronic-user 2-2.5x arm? Rec Table 17 grades >40 mg in naive CKD as IIa B2. Needs a visual check of the PDF figure.
- AKI: should the engine tell true AKI (oliguric, hypovolaemic) apart from pseudo-WRF during decongestion? This needs a user input such as 'diuretic response good / poor'.