Nefrología 2017-12-13 | doi: 10.1016/j.nefroe.2017.11.020

Palliative use of furosemide in continuous subcutaneous infusion in a renal transplant patient with heart failure

Uso paliativo de la furosemida en infusión continua subcutánea en un paciente trasplantado renal con fallo cardíaco

a Servicio de Nefrología, Fundació Salut Empordà, Figueres, Gerona, Spain
b Centro Sociosanitario Bernat Jaume, Fundació Salut Empordà, Figueres, Gerona, Spain

Cardiovascular disease is the first cause of death (30%) in renal transplant patients1 and in patients with kidney diseases in general, in these patients decompensated heart failure is frequent. The most common symptoms and comorbidities among patients with advanced stage of heart failure are dyspnea, pain, depression, fatigue and edema. Diuretics are the main treatment for dyspnea and edema, with furosemide being the most commonly used.2 The optimal effect of furosemide may require the intravenous route which implies hospital admission. It is also common the find difficulty in venipuncture of these patients. Therefore, the use of subcutaneous furosemide has been described in multiple cases in recent years with palliative purpose.3–6 We describe the case of a 65-year-old male patient who was admitted in February 2016 to our health center for symptom control due to complex pluripathology and significant functional impairment (Lawton 2/8 index and Barthel index 60/100). He presented with morbid obesity of years of evolution (BMI 48.7), arterial hypertension, diabetes mellitus type 2, severe obstructive sleep apnea syndrome, generalized osteoarthritis, multinodular goiter, kidney transplant in 1998 due to chronic renal failure of unknown etiology with glomerular filtration rate of 50–60ml/min/1.73m2, chronic lymphoedema in lower extremities, operated urethral stenosis, large abdominal hernia, pacemaker due to complete atrioventricular block and multiple hospital admissions due to decompensated heart failure and episodes of acute pulmonary edema during the last year. During the hospitalization, he again presented exacerbation of the edema in the all extremities and abdominal wall, and significant dyspnea at rest with 80% saturation and decreased state of consciousness. Due to the refractoriness of the oral furosemide (80mg/8h), with stable renal function and extremely difficult venipuncture, it was decided to administer a continuous subcutaneous perfusion of furosemide at a rate of 250mg/24h and given the poor overall prognosis comfort measures were adopted. The diuretic response was positive, increasing diuresis from 400 to 1000cc/day, with a decrease in edema and a greater sense of well-being. However, the patient presented with hematemesis and died 5 days later.

Continuous subcutaneous infusion is commonly used in palliative care units, with little information about its use in other medical specialties.7 The medications most commonly used subcutaneously are those administered in terminally ill patients, mainly oncology patients, and the experience of their use in other diseases is limited. For selected patients with advanced heart failure, continuous infusion of subcutaneous furosemide would allow them to continue their administration at home, or to continue their parenteral use if the possibility of intravenous route has been lost.3–6 Although there may be local adverse effects, these are of little relevance.4

By describing this case we want to emphasize that, although this patient had a very poor prognosis, the administration of furosemide by continuous subcutaneous infusion improved the symptoms of heart failure and decreased the aggressiveness in his treatment. Consequently, it would be necessary to perform further studies on the palliative use of subcutaneous furosemide in heart failure patients particularly in patients with kidney disease, and to assess the usefulness in renal transplant patients who reach a terminal situation or very advanced heart failure but with functional renal graft.

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¿Ha mejorado la supervivencia del paciente tras el trasplante renal en la era de la moderna inmunosupresión?
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