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Enhancement of diuresis with metolazone in infant paediatric cardiac intensive care patients

Published online by Cambridge University Press:  11 September 2017

Russell T. Wise
Affiliation:
Department of Pharmacy, Texas Children’s Hospital, Houston, Texas, United States of America
Brady S. Moffett*
Affiliation:
Department of Pharmacy, Texas Children’s Hospital, Houston, Texas, United States of America Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
Ayse Akcan-Arikan
Affiliation:
Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
Marianne Galati
Affiliation:
The Texas Medical Center Library, Houston, Texas, United States of America
Natasha Afonso
Affiliation:
Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
Paul A. Checchia
Affiliation:
Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
*
Correspondence to: B. S. Moffett, Pharm D, MPH, Department of Pharmacy, Texas Children’s Hospital, 6621 Fannin Street, Suite WB1120, Houston, TX 77030, United States of America. Tel: 832 824 6087; Fax: 832 825 5261; E-mail:bsmoffet@texaschildrens.org

Abstract

Background

Few data are available regarding the use of metolazone in infants in cardiac intensive care. Researchers need to carry out further evaluation to characterise the effects of this treatment in this population.

Methods

This is a descriptive, retrospective study carried out in patients less than a year old. These infants had received metolazone over a 2-year period in the paediatric cardiac intensive care unit at our institution. The primary goal was to measure the change in urine output from 24 hours before the start of metolazone therapy to 24 hours after. Patient demographic variables, laboratory data, and fluid-balance data were analysed.

Results

The study identified 97 infants with a mean age of 0.32±0.25 years. Their mean weight was 4.9±1.5 kg, and 58% of the participants were male. An overall 63% of them had undergone cardiovascular surgery. The baseline estimated creatinine clearance was 93±37 ml/minute/1.73 m2. Initially, the participants had received a metolazone dose of 0.27±0.10 mg/kg/day, the maximum dose being 0.43 mg/kg/day. They had also received other diuretics during metolazone initiation, such as furosemide (87.6%), spironolactone (58.8%), acetazolamide (11.3%), bumetanide (7.2%), and ethacrynic acid (1%). The median change in urine output after metolazone was 0.9 ml/kg/hour (interquartile range 0.15–1.9). The study categorised a total of 66 patients (68.0%) as responders. Multivariable analysis identified acetazolamide use (p=0.002) and increased fluid input in the 24 hours after metolazone initiation (p<0.001) as being significant for increased urine output. Changes in urine output were not associated with the dose of metolazone (p>0.05).

Conclusions

Metolazone increased urine output in a select group of patients. Efficacy can be maximised by strategic selection of patients.

Type
Original Articles
Copyright
© Cambridge University Press 2017 

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References

1. Selewski, DT, Cornell, TT, Blatt, NB, et al. Fluid overload and fluid removal in pediatric patients on extracorporeal membrane oxygenation requiring continuous renal replacement therapy. Crit Care Med 2012; 40: 26942699.Google Scholar
2. Selewski, DT, Cornell, TT, Lombel, RM, et al. Weight-based determination of fluid overload status and mortality in pediatric intensive care unit patients requiring continuous renal replacement therapy. Intensive Care Med 2011; 37: 11661173.Google ScholarPubMed
3. Sica, DA, Gehr, TW. Diuretic combinations in refractory oedema states: pharmacokinetic-pharmacodynamic relationships. Clin Pharmacokinet 1996; 30: 229249.Google Scholar
4. Schwartz, GJ, Brion, LP, Spitzer, A. The use of plasma creatinine concentration for estimating glomerular filtration rate in infants, children, and adolescents. Pediatr Clin North Am 1987; 34: 571590.Google Scholar
5. Arikan, AA, Zappitelli, M, Goldstein, SL, Naipaul, A, Jefferson, LS, Loftis, LL. Fluid overload is associated with impaired oxygenation and morbidity in critically ill children. Pediatr Crit Care Med 2012; 13: 253258.CrossRefGoogle ScholarPubMed
6. Arnold, WC. Efficacy of metolazone and furosemide in children with furosemide-resistant edema. Pediatrics 1984; 74: 872875.Google Scholar
7. Cachero, SD, Lofland, G, Springate, JE, Feld, LG. Combination of metolazone and furosemide in the treatment of edema in the first month of life. Child Nephrol Urol 1990; 10: 161163.Google ScholarPubMed
8. Dargie, HJ, Allison, ME, Kennedy, AC, Gray, MJ. High dosage metolazone in chronic renal failure. BMJ 1972; 4: 196198.CrossRefGoogle ScholarPubMed
9. Dargie, HJ, Allison, ME, Kennedy, AC, Gray, MJ. Efficacy of metolazone in patients with renal edema. Clin Nephrol 1974; 2: 157160.Google Scholar
10. Garin, EH, Richard, GA. Metolazone and furosemide therapy for edema. Pediatrics 1986; 77: 130131.CrossRefGoogle ScholarPubMed
11. Jentzer, JC, DeWald, TA, Hernandez, AF. Combination of loop diuretics with thiazide-type diuretics in heart failure. J Am Coll Cardiol 2010; 56: 15271534.Google Scholar
12. Kshirsagar, NA, Gupta, KC, Paul, T, et al. Effect of metolazone addition on furosemide resistant cases of edema. J Assoc Physicians India 1978; 26: 915923.Google ScholarPubMed
13. Segar, JL, Robillard, JE, Johnson, KJ, Bell, EF, Chemtob, S. Addition of metolazone to overcome tolerance to furosemide in infants with bronchopulmonary dysplasia. J Pediatrics 1992; 120: 966973.Google Scholar
14. Oh, SW, Han, SY. Loop diuretics in clinical practice. E & BP 2015; 13: 1721.Google Scholar